4.5 Documentation in Child’s Medical Record

Findings from the caries risk assessment, anticipatory guidance provided, and fluoride varnish application must be documented in the child’s medical record. A patient label or stamp can be made and placed in the medical record as a reminder about what needs to be documented.

Following is a sample patient label used in Connecticut.

Figure 8: Patient Label Template

The same information may also be adapted into a template for use in the electronic medical record. Click here for a sample template used in Massachusetts for the electronic medical record.

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