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

Legally, all entries in a patient's chart must be legible. Drawing a single line through an error ensures the original entry is still readable, which is crucial for legal transparency. The correction should be initialed and dated to identify who made the change and when. Other methods that obscure the original entry, like using correction fluid or a marker, are not considered legally sound.

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

SOAP is an acronym for Subjective, Objective, Assessment, and Plan. The 'Assessment' is the dentist's professional diagnosis or conclusion based on the subjective (what the patient says) and objective (what is observed) findings.

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

Objective information is factual, measurable, and observable data gathered by the dental team during an examination. This includes clinical findings like tooth mobility, caries, or periodontal pocket depths. Subjective information is what the patient reports or feels, such as pain or anxiety.

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

While the patient owns the information within their record and has the right to access it, the physical chart or electronic file itself is the property of the dentist or dental practice that created it. The practice acts as the custodian of the record.

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

It is crucial to document all communications and updates to a patient's record promptly and accurately. The note should be thorough, dated, and initialed. Having the patient review and sign the updated form at their next visit provides formal verification of the change. Simply adding it without documenting the source is incomplete, and delaying the update is unsafe.

(NDAEB) National Dental Assisting Examination Board Practice Test

(NDAEB) National Dental Assisting Examination Board Practice Test

FREE NDAEB Patient Records and Charting Questions and Answers