CIT Documentation & Record Keeping 2 — Questions and Answers
Question 1: Which document must be completed BEFORE a patient undergoes implant placement surgery?
- Post-operative care instructions
- Informed consent form (Correct answer)
- Insurance claim form
- Lab prescription
Correct answer: Informed consent form
Informed consent must be obtained and documented before any surgical procedure, including implant placement.
Question 2: When documenting a failed osseointegration, what information is MOST critical to record?
- The patient's insurance provider
- Timeline of events, implant specifications, and clinical observations (Correct answer)
- The referring dentist's contact information
- The patient's payment method
Correct answer: Timeline of events, implant specifications, and clinical observations
Recording the timeline, implant details, and clinical findings is essential for analyzing failure causes and guiding future treatment.
Question 3: A Certified Implantology Technician receives a lab prescription that is incomplete. What is the correct action?
- Proceed based on best judgment
- Contact the prescribing clinician for clarification before fabricating (Correct answer)
- Return the case without explanation
- Use a standard default design
Correct answer: Contact the prescribing clinician for clarification before fabricating
An incomplete prescription must be clarified with the prescribing clinician to ensure the restoration meets treatment requirements.
Question 4: Which retention period for implant patient records is most commonly required by US state dental board regulations?
- 1 year
- 3 years
- 7–10 years (Correct answer)
- 6 months
Correct answer: 7–10 years
Most US states require dental records to be retained for 7–10 years, with some states requiring longer retention for minors.
Question 5: What does a chain of custody document establish in an implant laboratory setting?
- The sequence of lab technicians who handled a case and when (Correct answer)
- The patient's dental history
- The sterilization log for instruments
- The invoice for prosthetic components
Correct answer: The sequence of lab technicians who handled a case and when
Chain of custody records track who handled a case at each stage to ensure accountability and traceability.
Question 6: Which of the following is an example of a violation of HIPAA in implant record keeping?
- Encrypting electronic patient files
- Faxing patient records without a cover sheet to an unintended recipient (Correct answer)
- Storing records in a locked cabinet
- Obtaining a signed release before sharing records
Correct answer: Faxing patient records without a cover sheet to an unintended recipient
Sending patient records without proper safeguards or to an unintended recipient constitutes a HIPAA privacy violation.
Question 7: In implant documentation, what is the purpose of recording the implant manufacturer's lot number?
- For billing purposes only
- To enable recall or identification in the event of a product safety issue (Correct answer)
- To satisfy insurance requirements
- To document the cost of the implant
Correct answer: To enable recall or identification in the event of a product safety issue
Lot numbers allow implants to be traced back to a specific manufacturing batch in case of recalls or safety alerts.
CIT Documentation & Record Keeping 2
Which document must be completed BEFORE a patient undergoes implant placement surgery?