Dental Quality Assurance Chart Review Audit Form Page 2
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2DENTAL QUALITY ASSURANCE
CHART REVIEW AUDIT FORM - 2
Patient Name
Identification #________________ _______________
C. Assessment of Treatment
Review the record for the first four criteria. Use judgment for the overall assessment of each of these criteria using
the explanations in the manual as a guide. All criteria deemed not acceptable must have an explanation in the
COMMENTS section.
1. Completeness of Diagnosis
COMMENTS
Check problems overlooked or not noted in treatment.
Caries
Gingivitis
Periodontitis
Missing teeth
TMD/facial pain
Oral pathology
Periapical pathology
Malocclusion
Space maintenance
Assessment of Diagnosis:
Acceptable
Not Acceptable
______________________________________________________________________________________
2. Integration of Non-dental Considerations
Check areas not appropriately considered in treatment.
Medical
Emotional
Medications
Lifestyle
Assessment of Non-dental Considerations:
Acceptable
Not Acceptable
Not Applicable
______________________________________________________________________________________
3. Appropriateness of Treatment
a. Appropriateness of Curative Treatment
Check services considered inappropriate.
Restorative
Periodontics
Endodontics
Removable prosthetics
Fixed prosthetics
Pulp protection
Oral surgery
Orthodontics
Space maintenance
Medication prescribed
Other ___________________
SPECIFY
Assessment of Appropriateness of Curative Treatment:
Acceptable
Not Acceptable
b. Appropriateness of Preventive Care
Review preventive care in record.
Assessment of Preventive Care:
Acceptable
Not Acceptable
______________________________________________________________________________________
4. Logical Sequence of Treatment
Check areas that are not judged to be in proper sequence.
Pain control
Caries control
Pulpal therapy
Preventive care
Orthodontics
Periodontal therapy
Space maintenance
Oral surgery
Restoration of missing teeth
Other_______________
SPECIFY
Assessment of Logical Sequence of Treatment:
Acceptable
Not Acceptable
______________________________________________________________________________________
5. Summary of Case Management
Indicate the overall quality of the total management of patient care.
Excellent
Above Standard
Adequate
Below Standard
Substandard
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