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Module 4: Anticipatory Guidance, Fluoride Varnish, and Referral

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

patient label used in Connecticut

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.