FREE NDAEB Patient Records and Charting Questions and Answers

Question 1

A dental assistant makes an incorrect entry in a patient's paper chart. What is the legally acceptable method for correcting this error?

Accepted Answer

Draw a single line through the incorrect entry, write the correct information, and then initial and date the change.

Answer

Use correction fluid to completely cover the error and write the correct information.

Answer

Erase the incorrect entry and write the correct information in the same space.

Answer

Black out the entry with a marker and write the correction in the margin.

Question 2

When documenting patient progress notes using the SOAP format, what does the 'A' represent?

Accepted Answer

Assessment - The dentist's diagnosis or professional impression.

Answer

Action - The treatment that was performed during the appointment.

Answer

Appointment - Details regarding the next scheduled visit.

Answer

Allergies - An update on the patient's known allergies.

Question 3

Which of the following would be recorded as 'Objective' information in a patient's chart?

Accepted Answer

The dentist's clinical finding of Class II mobility on tooth 3.6.

Answer

The patient's report of a sharp, throbbing pain in tooth 1.6.

Answer

The patient's statement that they are anxious about dental procedures.

Answer

The patient's mother's opinion on the child's daily brushing habits.

Question 4

According to Canadian dental regulations and privacy laws, who has legal ownership of the physical patient chart or electronic record?

Accepted Answer

The dentist or the dental practice.

Answer

The patient, as it contains their personal health information.

Answer

The provincial dental regulatory authority.

Answer

The dental assistant who created the chart entries.

Question 5

A patient of record calls the office to report they have started a new medication for hypertension. What is the most appropriate action for the dental assistant to take?

Accepted Answer

Make a detailed note in the patient's progress notes about the phone call, including the date, medication, and dosage, and flag the chart for the patient to sign an updated health history at their next visit.

Answer

Tell the patient to wait and update the information at their next appointment.

Answer

Inform the patient that medical history updates can only be completed in person with the dentist present.

Answer

Immediately add the new medication to the chart's medication list without making a progress note about the conversation.

Question 6

What is the primary purpose of the clinical examination and charting form within a comprehensive patient record?

Accepted Answer

To record all existing oral conditions, pathologies, and existing restorations.

Answer

To document the patient's financial information and insurance coverage.

Answer

To obtain the patient's blanket consent for all future dental procedures.

Answer

To list the patient's emergency contact information and medical alerts.