Dental Quality Assurance Chart Review Audit Form printable pdf download

Dental Quality Assurance Chart Review Audit Form

DENTAL QUALITY ASSURANCE

CHART REVIEW AUDIT FORM – 1

Date:_____________ Clinic: ___________________ Reviewer: __________________________________

Patient Name: ______________________________ Identification #: _______________________________

A. Radiographic Assessment

Review all radiographs taken during the last two years, check all criteria using the definitions in the manual.

YES

1. Sufficient quantity of films taken

2. All film mounts and packets dated

3. All film mounts and packets have patient identification number

4. All film mounts and packets have patient name

5. Quality - check problem areas

Insufficient contrast

Overlapping images

Distortion(elongation)

Apex not shown

Cone cut

Poor developing

Other_______________

SPECIFY

NOT

ACCEPTABLE

Overall estimation of quality of radiographs

B. Dental Record Assessment

Check if all criteria are present or absent. If present, check if acceptable or not acceptable using definitions in the

manual.

NOT

PRESENT

ABSENT

ACCEPTABLE

1. Patient identification

2. Dental consent

3. Medical history

4. Extraoral/intraoral examination

5. Dental charting

6. Problem list/treatment plan

7. Progress notes

COMMENTS:

Dental Quality Assurance Chart Review Audit Form