Dental Office Procedures for Dental Assisting Exam Study Guide (page 2)

Updated on Jun 23, 2011

Working with Dental Office Documents

The assistant must understand the importance of the Health Insurance Portability and Accountability Act (HIPAA). This is a federal act that requires the dental office to transmit certain patient health information electronically to protect the health information. This act also covers keeping the patient’s personal and financial information private.

The patient’s record consists of many documents. These records can be kept on paper, in electronic form, or both. The health history and registration form is completed on the patient’s first visit to the office. The clinical chart is where the assistant and doctor note the findings of the examination and indicate all procedures completed. There are three different tooth numbering systems, and charting symbols are used along with clinical abbreviations to note information in the patient’s clinical chart.

Parts of the patient’s clinical record include:

Health History

The health history gives the doctor an overview of the patient’s past and present medical conditions, medications, and allergies.

Registration Form

The registration form provides the patient’s personal and financial information. This includes facts such as address, employer, birth date, insurance information, and so on.

Clinical Chart

The clinical chart identifies any of the patient’s pre-existing conditions, and it is also here that the dentist outlines the treatment plan and services rendered.

Treatment Plans

Once the dentist has thoroughly examined the patient, he or she will prepare a written treatment plan that outlines the proposed treatment, an estimate of the costs, and any other options. Dental assistants must be familiar with all dental terminology to be able to understand and explain treatment plans. For example, if a plan shows an MOD restoration on tooth #3, that is a three-surface restoration on a maxillary molar. Then, if it calls for a PFM crown on tooth #30, the assistant should know that is a porcelain-to-metal crown on a mandibular molar. Similarly, treatment for tooth #19 in the Universal Numbering System refers to the mandibular left first molar. An assistant can explain how pit and fissure sealants prevent decay on the developmental faults on both primary and permanent teeth.


Dentists write prescriptions for medications as needed, and a copy is usually made and stored in the patient’s dental chart.

Lab Requisitions

The dentist must create a written requisition for each appliance to be fabricated in the dental laboratory. This includes partials, dentures, crowns, bridges, surgical stents, athletic mouth guards, and bleaching trays.


Radiographs are usually taken on new patients and periodically on returning patients at their recall appointments. Radiographs may be taken digitally or with film. There are two types of radiographs: intraoral or extraoral.

Intraoral Pictures

The dental office may utilize an intraoral camera to document the patient’s intraoral condition. These pictures are either printed or stored electronically in the patient’s chart.

Referrals/Correspondence from Other Doctors

The office may receive letters or radiographs from specialists or referring doctors that may become part of the patient’s chart.

Consent Forms and Other Non-Clinical Documents

Once details of the dental treatment plan have been explained, the patient must then sign an informed consent form. Minors must have a parent or guardian sign the consent form. No work can be done without a signed consent form. For example, if a 14-year-old arrived at the dental office for a scheduled treatment without the forms signed by a parent or guardian, the dental assistant would have to reschedule the patient.

The ledger, which shows the financial record of the patient’s dental care, is part of the patient’s record; however, it is not part of the clinical record.

Filing systems are used to store records. There are different types of filing systems used in a dental office. These include: alphabetical, numerical, chronological, subject, and geographical. The alphabetical system places charts or documents in alphabetical order by the last name, then first name. Chronological filing would be by the date (1–31), and is used when storing insurance claims. Subject filing is also done alphabetically by the name of the subject. Geographical filing is done by a division of territory (state, city, or street).

Recall cards are filed in a chronological file system, patient records are filed in an alphabetical file system or a numerical filing system, and the contents inside the patient’s record are filed in chronological order with the most current contents at the top.

A tickler file is a chronological file used to remind the assistant of daily, weekly, or monthly tasks to be completed.

Appointment Management

The dental office’s success pivots on the appointment scheduling. This task may be assigned to one individual in the practice who then can implement the practice’s scheduling policies. The usual sequence of an appointment is:

  1. Initial examination appointment
  2. Diagnosis and formulation of treatment plan
  3. Consultation with patient regarding treatment plan
  4. Treatment appointment scheduled

Appointment books are either traditional paper books or computerized. There are many advantages in using the computerized book. These advantages include neatness and legibility, ability to access the patient’s record and treatment plan, and various screen viewing modes. Additionally, operators or treatment rooms can be color coded, daily and monthly production can be monitored and scheduled, procedures can be posted to several different records from only one entry, and searching for appointment openings can be made easier. The one advantage a paper book has over a computerized book is if the power goes out or the computer crashes, there is still a way to see who is scheduled to come in. Some dental practices still use paper appointment books as a backup to the electronic system, while others perform a daily electronic backup.

Dental assistants must be familiar with logistics to ensure proper timing of appointments and managing time slots accordingly. For example, bridge work is generally done in two stages. The dental assistant must know how long the lab needs to prepare and then return the denture to the dental office in order to book the cementation appointment for an appropriate date. It is frustrating for everyone if the patient turns up for an appointment but there is no denture to be placed. Therefore, a crown cementation appointment is usually scheduled two weeks after the preparation appointment to allow the lab sufficient time.

It is best to schedule young children in the early morning so as not to interfere with their nap times. Older patients often like appointments in the late mornings or early afternoons to avoid rush hour traffic, and sometimes find it difficult to move quickly in the early morning. Late afternoon and evening appointments are good for working adults. Patients with special needs should be accommodated. For example, diabetic patients should be given early morning appointments. That way, patients can have their medication and eat a normal breakfast so that their sugar level is not compromised. If the surgery is completed at 8:30, the patient will be able to have lunch and keep glucose levels stable.

Emergency patients are asked specific questions on the phone when they call, such as:

  • “How long have you been in discomfort?”
  • “Which area of the mouth are you experiencing discomfort?”
  • “Is the discomfort a sharp pain or dull ache?”
  • “Is the tooth sensitive to hot, cold, or pressure?”

Emergency patients should be reassured that the dentist will see them as soon as possible to help relieve their discomfort.

The appointment book has a matrix, which is the framework or outline of the schedule. Holidays, lunch hours, starting times, ending times, vacations, continuing education seminars and meetings, and buffer times are all elements of the matrix.

A unit is an increment of time used when determining the length of the particular appointment. Most dental appointment books are made up of ten- or 15-minute units.

A buffer period is a short period of time in the day that is left open for scheduling emergency patients or used as catch-up time for the dentist and chairside assistant in a busy schedule. When a patient does not show up and does not call to cancel, this is known as a broken appointment. Skilled assistants are able to juggle these open time slots so that the dentist and staff are never idle. The assistant and dentist can use any extra time in the open schedule to write up charts, pour models, return patient phone calls, or make lab pick-up arrangements.

Prime time is the time most requested by patients. This is usually the first and last appointments of the day. Many working patients or parents prefer early morning or late afternoon appointments. This way, they can stop at the dental office before work or school, or leave straight from their dental appointment and go home in the afternoon.

A treatment plan is a list of the dental procedures to be completed for the patient, and it is divided into appointment visits with specific time allotments for each visit. The appointments are made based on the treatment plan. They are listed from most urgent to least important or elective procedures.

Short appointments can be dovetailed, which means working a second patient into the schedule during another patient’s long treatment appointment, either at the beginning or end of the long appointment. The second patient is booked so that the chairside assistant can remain with the fi rst patient while the dentist examines the second patient.

Production goals should be considered when appointing patient treatment. The office usually sets a minimum figure of how many new patients, units of crown and bridge, and hygiene production are done on a daily basis. This minimum goal is what covers the office overhead.

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