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7UNIVERSITY DENTAL CENTER, RYAN WHITE PROGRAM
DENTAL RECORD REVIEW ANNUAL REPORT
JANUARY 1, 200_ THRU DECEMBER 31, 200_
According to the UMDNJ – New Jersey Dental School Standards of Care
DENTAL RECORDS All dental school records will be maintained in a manner that is
current, detailed, organized, and permit effective and confidential patient care and quality
review.
Indicator: At least 90 percent of items reviewed on the chart audit were correct.
HEALTH HISTORY ASSESSMENT
TOTAL REVIEWS : TOTAL CORRECT
I
Assessment of patient’s current dental status
II
CD4 and viral load results
III
Contact information for primary care providers and
whether the patient is receiving care
IV
Current medications and changes in regimen
V
Allergies
VI
Laboratory data
VII
Hepatitis B & C status
VIII
Platelet counts/PT PTT/INR
IX
Charting of hard tissue decay pathology or
condition
X
Soft tissue pathology or condition
XI
Radiographs of diagnostic quality
XII
Overall periodontal case type
XIII
Pocket or probing depths (where indicated)
XIV
Gingival inflammation
XV
Bleeding assessment
An extraoral (head and neck) exam was performed
XVI
at least annually.
XVII
A written treatment plan was updated at least
annually.
XVIII
Progress toward completion of treatment plans is
being made.
XIX
Brushing and flossing techniques
XX
Dietary counseling
XXI
Soft tissue assessment
XXII
Management of soft tissue pathology
PERCENTAGE OF ITEMS REVIEWED
CORRECT
5 - University of Medicine and Dentistry of New Jersey, NJ Dental School 973.972.0190
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