Documentation/Patient Records

Patient records are a vital part of your practice. Among other things, they contain information about the patient’s treatment plan and care that has been delivered. Dental records are especially important when submitting dental benefit claims or responding to lawsuits. While the dental record could be viewed as a form of insurance for your practice, make sure you include only those facts that are relevant to providing dental care. Follow the record keeping format you establish stringently and always keep in mind that what you write in the record could be read aloud in a court of law. After all, the patient record is a legal document.

• Whomever performs the treatment should document it in the record. All entries should be initialed or signed even if you are the only person who makes an entry in the patient record.

• You, the dentist, are responsible for the codes selected and documented in the patient record and billing systems. No matter who enters the information, you must make sure all of the information, including any procedures codes referenced, is correct.

• Information typically noted in the dental record includes:
  • personal data, such as the patient’s name, birth date, address and contact information including home, work and mobile telephone numbers
  • the patient’s place of employment
  • medical and dental histories, notes and updates
  • progress and treatment notes
  • recaps of conversations about the nature of any proposed treatment, the potential benefits and risks associated with that treatment, any alternatives to the treatment proposed, and the potential risks and benefits of alternative treatment, including no treatment. Include conversations that took place in the office, over the phone and even calls received outside the office. Make sure that the recaps are dated and initialed.
  • diagnostic records, including charts and study models
  • medication prescriptions, including types, dose, amount, directions for use and number of refills
  • radiographs
  • photographs
  • intraoral photographs
  • treatment plan notes
  • patient complaints and resolutions
  • referral letters and consultations with referring or referral dentists and/or physicians
  • patient noncompliance and missed appointment notes
  • follow-up and periodic visit records
  • postoperative or home instructions, or a notation about any pamphlets or reference materials provided
  • Informed consent/refusal forms
  • waivers and authorizations
  • correspondence, including a dismissal letter; if appropriate
  • Information that should not be noted in the dental record includes:
    • any financial information, including ledger cards, insurance benefit breakdowns, insurance claims, and payment vouchers. The patient’s financial records are not part of the clinical record and should be maintained separately.
    • personal opinions or criticisms. While it is okay to document a patient’s refusal to accept the recommended treatment plan and information about cancelled appointments, be aware that disparaging comments and even informal notes written in the margins of a patient’s chart must be shared if a lawsuit is filed.
    • keep patients’ personal information in a location separate from their medical and dental records. Collecting that information on a separate form will make it easier to maintain separate files. Encourage team members to note each patient’s special interests, hobbies and activities on that form.
    • Audit your dental records on a regular basis.
      • Auditing charts ensures that your records match those maintained by insurance companies, which often review a certain number of charts based on how many of their covered patients you’ve seen.
      • Audits allow you to confirm that patients have signed off on treatment plans and confirm that any changes in care from the original plan were discussed and approved.
      • Conduct clinical audits over time. This can serve as a quality assurance process that gives you direction for tweaking practice systems to improve operations. It can also facilitate brainstorming within the practice to avoid mistakes in the future.
      • Announce all changes in the protocols or processes for maintaining patient records during staff meetings. Assign a staff member to take notes of the discussion so there’s an official record of what specific changes were communicated, when they were communicated and to whom.
      • Add a review of charts to the steps detailed on your close of the day sheet and follow each of the steps outlined.
        • Make sure everything was billed out correctly and completely.