Referral Form Page 4
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7UNIVERSITY DENTAL CENTER, RYAN WHITE PROGRAM
DENTAL RECORD REVIEW
PATIENT’S NAME:_______________________ CHART NUMBER:____________
PROVIDER’S NAME:_____________________ DATE:_______________________
A health history assessment has been obtained at least annually and includes documentation within
the last 12 months of the following:
I
Assessment of patient’s current dental status
YES
NO
II
CD4 and viral load results
YES
NO
III
Contact information for primary care providers and whether the patient is receiving
YES
NO
care
IV
Current medications and changes in regimen
YES
NO
V
Allergies
YES
NO
VI
Laboratory data
YES
NO
VII
Hepatitis B & C status
YES
NO
VIII
Platelet counts/PT PTT/INR
YES
NO
An intraoral exam was performed at least annually and included the following components:
IX
Charting of hard tissue decay pathology or condition
YES
NO
X
Soft tissue pathology or condition
YES
NO
XI
Radiographs of diagnostic quality
YES
NO
A periodontal exam was performed at least annually, and included the following components:
XII
Overall periodontal case type
YES
NO
XIII
Pocket or probing depths (where indicated)
YES
NO
XIV
Gingival inflammation
YES
NO
XV
Bleeding assessment
YES
NO
XVI
An extraoral (head and neck) exam was performed at least annually.
YES
NO
XVII
A written treatment plan was updated at least annually.
YES
NO
XVIII
Progress toward completion of treatment plans is being made.
YES
NO
Oral hygiene instruction was provided to the patient annually, and included the following
components:
XIX
Brushing and flossing techniques
YES
NO
XX
Dietary counseling
YES
NO
XXI
Soft tissue assessment
YES
NO
XXII
Management of soft tissue pathology
YES
NO
4 - University of Medicine and Dentistry of New Jersey, NJ Dental School 973.972.0190
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