**7. Documentation**

As in all other endeavors, if it is not written it has not been done. Organizations offering optimal care ought to create detailed documentation and provide an accurate and secure record for the basis of ongoing care and outcome assessments. Documenting details of a patient at every stage makes developing the treatment plan easier for cleft patients. As shown in **Figure 2**, documentation can be divided into five vital areas.

**Figure 2.** Key documentation areas.

#### **• Medical records**

These forms, whether written or electronic, should be identical throughout the organization. They should be comprehensive, explicit, and clear. The history section should include family background, demographic details, and previous history of cleft in the family. A complete record of physical examination and medical diagnosis of data must be entered. Multiple copies should be made for each file. This allows one copy to be left with patient's medical chart in the host country, and another copy to be used for tracking and future analysis.

#### • **Patient photographs**

**7. Documentation**

50 Designing Strategies for Cleft Lip and Palate Care

**• Medical records**

**Figure 2.** Key documentation areas.

future analysis.

As in all other endeavors, if it is not written it has not been done. Organizations offering optimal care ought to create detailed documentation and provide an accurate and secure record for the basis of ongoing care and outcome assessments. Documenting details of a patient at every stage makes developing the treatment plan easier for cleft patients. As shown in

These forms, whether written or electronic, should be identical throughout the organization. They should be comprehensive, explicit, and clear. The history section should include family background, demographic details, and previous history of cleft in the family. A complete record of physical examination and medical diagnosis of data must be entered. Multiple copies should be made for each file. This allows one copy to be left with patient's medical chart in the host country, and another copy to be used for tracking and

**Figure 2**, documentation can be divided into five vital areas.

Pre- and post-operative photographs of patients are also important as they are a key factor in analyzing results. These photographs can be further used for outcome assessment and research purposes.

#### • **Orthodontic and facial diagnostic study casts**

Pre-, progress, and post-nasoalveolar molding (NAM) facial and orthodontic diagnostic study casts are imperative for the fabrication of NAM appliances, orthodontic appliances, and orthopedic appliances. Additionally, they are required to evaluate treatment progress, outcomes assessment, and for research purposes.

#### • **Radiographic records**

Pre-, progress, and post-orthodontic and surgical imaging should be taken as indicated in order to aid in the diagnosis and treatment planning of craniofacial orthodontics, dentofacial orthopedics, and orthognathic surgery. Like photographs and diagnostic study cases, they are also useful for research purposes.

#### • **Consent forms**

Lastly, consent forms are an integral part of the documentation process. All patients and guardians must read and sign a consent form, which should be comprehensive and clear. The form must include the nature of the operation and its risks, use of anesthesia, potential blood transfusion, HIV, and hepatitis testing in the case of needle stick and permission for taking photographs. The families should also be informed, and oral or written consent should be taken if the data are to be used for research purposes. When language difference exists, professionals should utilize interpreters to assure informed consents are properly documented prior to delivery of care and surgery.

All members of the multidisciplinary cleft care team are responsible for documentation. The cleft care facility should work systematically to ensure that documentation tools are readily available to all health care providers, while at the same time respecting and maintaining patient confidentiality.
