Title: Record treatment rendered.
Course: Dental Careers I (14054-I) > Section: Recording Patient Information and Assessment

Recording should include

- tooth number
- dental restoration
- oral surgery
- medications or prescriptions
- anesthetic
- postoperative instructions (reviewed and understood by the patient)
- dental procedures (i.e., impressions, fluoride, vital signs)
- date
- operator
- assistant.

Process/Skill Questions

- How often should a patient's health history be updated?

- Why should chart entries be written in ink? How should changes to entries be made?
- Why, or why not, do all recorded procedures require a tooth number?
- How should a multiple-tooth-restoration appointment be recorded?
- Why is it necessary to record all materials used in a procedure?
- How could waiting to record information be problematic?