The Dental Record Form is a crucial document used in New Zealand dental practices to maintain comprehensive patient records in accordance with national healthcare regulations. This form is required for every patient and must be maintained throughout their course of treatment, serving as both a legal document and a clinical tool. It ensures compliance with the Health Information Privacy Code 2020, the Health Practitioners Competence Assurance Act 2003, and the Dental Council of New Zealand's requirements for patient record keeping. The form includes sections for patient information, medical history, treatment plans, progress notes, and consent documentation, making it essential for continuity of care and legal protection for both practitioners and patients.
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1. Patient Information: Basic patient details including full name, date of birth, contact information, NHI number, and emergency contact details
2. Medical History: Comprehensive medical history including current medications, allergies, chronic conditions, and previous surgeries
3. Dental History: Previous dental treatments, concerns, and oral health habits
4. Current Oral Assessment: Detailed chart of current oral condition including existing restorations, missing teeth, and periodontal status
5. Treatment Plan: Documentation of proposed treatments, priorities, and estimated costs
6. Progress Notes: Chronological record of all dental visits, treatments performed, and clinical observations
7. Consent Record: Documentation of patient consent for examinations, treatments, and information sharing
8. Payment Information: Financial arrangements, insurance details, and payment history
1. Orthodontic Assessment: Specific section for patients requiring orthodontic treatment evaluation and planning
2. Pediatric Information: Additional information specific to child patients, including growth and development notes
3. Prosthetic Record: Detailed information for patients with dentures or other prosthetic appliances
4. Special Needs Assessment: Additional considerations and accommodations for patients with special healthcare needs
5. Radiograph Log: Tracking of x-rays taken and their findings
6. Sedation Record: For patients requiring sedation during treatment, including pre- and post-operative monitoring
1. Medical History Questionnaire: Detailed questionnaire for patient completion regarding medical history
2. Dental Charting Sheet: Visual representation of patient's dental status including tooth conditions and treatments
3. Treatment Consent Forms: Specific consent forms for various dental procedures
4. Privacy Policy Statement: Details of how patient information is collected, used, and protected
5. Fee Schedule: Current fee structure for dental services
6. Photography Consent Form: Consent for taking and using dental photographs for treatment planning and documentation
Authors
Relevant legal definitions
Clauses
Relevant Industries
Healthcare
Dental Services
Medical Records Management
Insurance
Public Health
Healthcare Administration
Healthcare Technology
Relevant Teams
Administration
Clinical Operations
Patient Care
Records Management
Compliance
Reception
Finance
Quality Assurance
Relevant Roles
Dentist
Dental Hygienist
Dental Assistant
Practice Manager
Dental Receptionist
Dental Specialist
Orthodontist
Oral Surgeon
Healthcare Administrator
Compliance Officer
Insurance Coordinator
Medical Records Manager
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