 Hello everyone, welcome back to another session in dentistry and more today we have a topic from public health industry that is dental records Previously I applauded one session about clinical practice management so in that session I was More explaining about how to set up a clinic its location the Instruments or so this session is exclusively for dental records not in detail, but a brief idea about dental records So why to keep the dental records? Okay, the first thing is to provide quality care okay, and also for Having a good clinical practice. So if we have dental records backup system Our practice will be very good because we need or to Take the case history twice because the patient might have already Come to a clinic. So we just go to the previous records and just Have a look at the case history So very few things might have changed. So we can ask the newer things and start the practice and also To conduct clinical trials because since we have data we can have good clinical trials it helps to find out new things that is part of research and It helps us promote teaching because we have lots of data. We can teach others By comparing the old data and new data and this is most crucial thing that is it Protect us or protect the dentist from litigation. Okay, so it act as a protective evidence against the Accusation against the dentist and it also helps us in referral because when we have data we can Refer this patient To an extent is because we need not to explain anything about the patient We just have the data and send the patient with the all the records to the Specialist and also for the historical purpose Because we know in history many people were identified just because of the dental records, we know the history of at all Hitler records next we have The points to be noted when we take dental records We need to have standardized method. That is diagrammatic charts Okay, so we should not use any unsanitized method for taking case history We need to have good standardized method for every patient and we should always include Most of the details which includes non-lational areas non-important areas and The investigation details also should be properly recorded that includes the photography cast models lab findings the biopsy and Hematological findings all these things should be included So what are the components of a dental record? so it should have details of patients record that is the case history and all those things what we discussed in the previous slide case history Investigation all those things and the business record that includes the money thing Everything about the money and the third thing is the tracks I mean what all drinks are prescribed and how many drinks the patient has taken everything should be Not at all. So that was a dental record component Then we should never forget these things that is the dentist is a responsible person Not the patient so when patient says an accusation I call against the dentist We should be very cautious because we are the responsible person So our data always should be objective that is from the dentist perspective not from the patient's perspective and in every document we should always take the signature of the patient and It should be a informed Concerned informed concern means the patient should be knowing in and out of the procedure whatever procedure whatever Investigation we are planning to carry out in the patient He should know in and out about the procedure or investigation its limitations in alternatives its benefits Disadvantages everything and he should sign the document. Okay, so we are the responsible person It should be very objective and signature is must and it should be informed consent and we should always record all the Bill details with the date and amount and all the bills from the lab Whatever we have purchased from the lab Like the dentures artificial crowns implants all those things with the bills and dates if the dentist makes any conversation with patient with regard to the Satisfaction or if patient has any queries or any complaints all the phone calls should be recorded for the future legal purposes and All other direct communication should be written and sign is not written and signed the patient might change his words and All the details of drugs and it's dosage quantity everything should be written down All details of drugs with dates dosage quantity everything should be recorded. Okay, and we should take cases three Like a and P that is soap is acronym for the format where how we should Make our case history or record the dental data that is S4 subjective data or for objective finding a for Assessment before plan that is we ask the patient about head subjective problems. Then we make our assessment Then we assess that is a diagnosis and make the plans based on the diagnosis So how we should store the records that is we need to have shelves for storing it and better We need to have a lateral sorry lateral and open shelf and There should be a color coding color coding is very easy We need to have different colors. That is yellow Green red color calling is very much because many dental offices use a color-coded filling system for patient record files We need to have color Coded labels usually the first two letters of the patient's last name and active data treatment So in any way we can have different colors for different Set of patients and we can categorize based on these colors and Electronic data now. Nowadays. We have lots of softwares and computer system to store data so We can store the data in our computers or laptops and this is the most crucial thing How long to be stored all these data? How long we need to store? as per the revised dentist code of ethics in 2014 we need to store these data for three years Same with medical council of in their medical records also they need to store for three years And it is also said that the IP Records the inpatient records for five years and the outpatient records for three years and the mlr for indefinite period Okay, so we can throw it off after five years the OP records after three years But the medical legal records for indefinite period. Okay, so this is three years as per the revised dentist code of ethics So and there are two types of records one is active and next is inactive one active is Patients who are undergoing treatment and regularly coming to the clinic inactive one who is not returned to the clinic for at least past 24 months so that was all about dental records maintenance and its importance I was explaining you about the duration and how to store it what is the difference between IPOP and mlr and The soap acronym how we should record the data Then the importance of signature in firm concern and objective nature of data then the components of our Records and the introduction part, so I'll come up with a new topic in dentistry and mark Thank you