What documents must be included in a patient's dental record?

Including patient history, examination results, and test results in a patient's dental record is critical for several reasons. This comprehensive documentation ensures that a complete picture of the patient's oral health is maintained, which is essential for effective treatment planning and continuity of care.

Patient history provides valuable insights into the individual's medical background, allergies, and previous dental treatments, which influences current decision-making. Examination results document the practitioner's findings during dental assessments, which are crucial for diagnosing conditions and determining necessary interventions. Test results offer objective data, such as radiographs or laboratory analyses, that support clinical judgments and enhance treatment accuracy.

In contrast, simply documenting payment histories, petition and complaint forms, or insurance claims is insufficient for a dental record. These elements do not provide the necessary clinical information that contributes to a patient's overall oral health management. Therefore, the inclusion of patient history, examination results, and test results is vital for both legal and healthcare best practices in dental hygiene.