Medical Record Department (MRD) in Dentistry

The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient’s, medical history and care across time within one particular health care provider's jurisdiction. A medical record includes a variety of types of "notes" entered over time by healthcare professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite. The terms are used for the written (paper notes), physical (image films) and digital records that exist for each individual patient and for the body of information found therein.

Dental records consist of documents related to the history of present illness, clinical examination, diagnosis, treatment done, and the prognosis. A thorough knowledge of dental records is essential for the practicing dentist, as it not only has a forensic application, but also a legal implication with respect to insurance and consumerism. 

The Electronic Medical Record (EMR) is an integral part of the medical standard of care—today and in the future. EMR is sometimes referred to as Electronic Dental Record (EDR) or Electronic Health Record (EHR). This key feature guides you through clinical record-keeping in a standard SOAP format (subjective, objective, assessment, plan). It allows key patient information to be centralized— demographic, medical/dental, social and financial— all within your practice management software. EMR eliminates multiple paper charts and provides controlled, secure and instant digital access to comprehensive information. Some EMRs incorporate a range of supporting technologies to become a fully integrated component of the practice management software, thereby allowing even more access to vital information at the point of care. This information is accessible from any secure workstation, so there are no interruptions during the patient visit to retrieve information.