Chart Review Form.xlsx

	A	F	G	H	I	J	K	L	M	N	O	P	Q	R
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3	La Clinica Dental Provider Chart Review Form
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5	Date of Review: ***	Reviewing Dentist: ***						Trimester Reviewed: ***
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7			Chart 1		Chart 2		Chart 3		Chart 4		Chart 5		Chart 6
8	Patient MRN
9	Most recent comprehensive exam note		YES	NO	YES	NO	YES	NO	YES	NO	YES	NO	YES	NO
10	1. Soft Tissue findings noted? (in most recent exam note)
11	2. Dental findings noted-caries, missing teeth, dental needs? (most recent exam note)
12	3. Periodontal findings / Diagnosis/Classification noted? (most recent exam note)
13	4. Caries risk noted (most recent exam note)
14	5. Planned tx matches Exam note Findings and Dx
15	6. Number of Xrays taken / number exposures documented? (most recent exam note)
16	7. Med History summarized present and complete (most recent exam note)?
17	8. PSR probing completed if adult new patient exam?
18	9. Caries Risk Code Completed
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20			Chart 1		Chart 2		Chart 3		Chart 4		Chart 5		Chart 6
21	Radiographs from most recent comprehensive exam		YES	NO	YES	NO	YES	NO	YES	NO	YES	NO	YES	NO
22	1. Radiographs are Current
23	2. Appropriate Survey/ type of Xrays taken?
24	3. Images diagnostic quality: no need for retakes?
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26			Chart 1		Chart 2		Chart 3		Chart 4		Chart 5		Chart 6
27	One treatment note completed after most recent exam		YES	NO	YES	NO	YES	NO	YES	NO	YES	NO	YES	NO
28	1. Appropriate testing done (i.e. endodontic testing for deep caries or crown prep)?
29	2. Diagnosis documented? (In treatment notes)
30	3. Record is complete and appropriate for treatment rendered?
31	4. Tx Documentation is complete, tooth area, anesthetic (type, amount, & location),procedure and/or materials,signed with Doctor's and Assistant's names,etc.?
32	5. Follow up appointment is indicated in clinical record?
33	6. PARQ and RPMH noted
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35	Do you recommend a more in depth quality review of this case?		Chart 1		Chart 2		Chart 3		Chart 4		Chart 5		Chart 6
36			YES	NO	YES	NO	YES	NO	YES	NO	YES	NO	YES	NO
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39	In considering a recommendation for more in depth review please take into account: - Quality of treatment visible radiographically (Crowns, root canals, fillings etc). - Whether treatment follows an appropriate sequence. - Reasonableness of overall treament plan. - Any documentation indicating an adverse outcome. - Whether proper referrals appear to have been made - Marking "yes" does not indicate that standards of care were breached or adverse outcomes could have been avoided. As always, we as a group of dentists recognize that the patient record and radiographs are not a perfect substitute or representation of challenges posed by clinical situations.
40	For all "No" answers please provide a brief description of your concern under the tab marked "Feedback For Them" below.
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43	Chief Dental Officer Comments:
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45	Dental Quality Asurance Director Comments:
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47	Protected as risk and quality data under ORS 41.675; not to be disclosed voluntarily or involuntarily.
48	Dentist Chart Reviews Form (La Clinica 2020)
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