Where do you store this information? DENTAL RECORD

Function or Purpose of Clinical Chart Record of patient’s medical and dental initial examination Chronological record of treatment provided Legal documentation for patient, third party payers, patient’s heirs, dentist Tool for quality assessment Forensic record

Chart Necessities *Chronological *Legible (no marked out entries) *Permanent ink *Factual *Entries identified with patient name *Notes legally signed by provider

Effective Record Keeping in Dental Practice: “ Rules of the Road ” Donald Falace, DMD Professor and Division chief Oral Diagnosis and Oral Medicine

The following guidelines are the result of many years of teaching and monitoring record keeping in the dental school setting. They are also the result of having been a consultant and expert witness in numerous malpractice cases They are simply general principles of good practice for the protection and benefit of both dentist and patient There are no uniform universally accepted guidelines, nor do the Kentucky statutes provide guidelines

Importance of good dental records The volume of patients and the length of time between visits makes good records essential to the continuing care and treatment of patients After patient care is completed, the only evidence of what occurred is: –Memory of the patient –Memory of the health care provider –The written record

Purposes of the dental record Communicates essential information among members of the healthcare team Provides a permanent written record of the patient’s medical and dental conditions at the initial examination Provides facts and documentation justifying the need for treatment Provides a record of treatment provided Provides legal documentation on behalf of the patient, third party payers, or dentist Provides forensic documentation

What should be included in the dental record? Personal and/or identifying information Source of the information if other than the patient (parent, spouse, guardian) Document if poor historian or if patient reluctant to provide information Medical history, signed by patient and dentist; significant problems recognized and acknowledged; referral to a physician documented Dental history and chief complaint(s) Complete initial examination findings including oral cancer screening, periodontal charting, occlusion, caries and restorations, pulp testing and radiographs; clinical findings are documented that are essential to diagnosis or to patient care Diagnoses are documented and explained if questionable or unclear Written treatment plan with signed consent, including risks and benefits of alternative treatments Treatment record of procedures; explain reasoning if action is not obvious or contrary to the usual; complications are documented

Medical history updates Ideally, the medical history should be updated at each appointment A simple question to the patient, such as, “Have there been any changes in your health status since you were here last? Are you taking any new or different medicines?” This information should be noted in the progress note; “no changes in health status”; “discontinued propanolol and now taking lisinopril for hypertension” A new medical history questionnaire should be completed annually

Why you did, what you did! Is your treatment supported and justified by the information documented in the chart, including history, examination, charting, testing, radiographs and treatment plan? For example, if a tooth was extracted, is it clear from the record why it was necessary and justified?

Progress notes Progress notes should be written immediately after seeing the patient The progress note should be written in such a way and with adequate detail that whoever reads it (an educated non-dentist) can understand what was done, how it was done and why it was done. Clear and concise; thorough and accurate Volume does not necessarily equate with quality; do not be unnecessarily wordy Be consistent in the way in which you write your notes The language used in a progress note is often as important as what was written. Choose words carefully! Entries must be made in ink and must be legible Terms and abbreviations should be unambiguous, consistent and appropriate

…..continued Every entry should be dated and signed If written by an auxilliary, the dentist should counter sign to indicate that the note was read and that the dentist is in agreement with what was written Do not skip lines or leave blank spaces between entries Document missed or cancelled appointments Record all phone conversations with the patient Document instructions given to a patient Record all prescriptions provided to a patient; it is good practice to copy the prescription as written, including drug prescribed, strength, number dispensed, directions to the patient, and authorizations for refills; if prescription is called into the pharmacy, record the name and phone number of the pharmacy

….continued Describe unexpected or unusual intra-operative findings or special situations encountered –Pulp exposure or near exposure –Tortuous root canal anatomy –Presence of swelling, pus, bleeding –Necessity for unconventional treatment –Inability to obtain good anesthesia –Patient reactions This information may be important to explain future circumstances or complaints

Documenting adverse events Examples: accidents, unexpected or unintended outcomes, medical emergencies Describe the occurrence of events in an objective manner; record only the facts but be thorough Include comments made by the patient; quote directly when possible Indicate that the patient was informed of the event Indicate what was done after the event and what type of follow up care is planned Document all follow up care including phone calls, letters, and appointments

Can auxilliaries make chart entries? Yes. Auxilliaries can make chart entries which can save time for the dentist; be sure the auxilliary is trained in good record keeping practices and that whoever wrote the note, signs the note All entries should be read and signed (or initialed) by the dentist to indicate that the dentist actually read and agrees with the information. Additions and/or corrections are ok, and are further proof that the entry was actually read All interactions or conversations between the patient and auxilliaries that involve patient care should be documented

Conventional Wisdom “If it isn’t written down, it didn’t happen” Lack of a statement of findings may be interpreted as the procedure not having been done or a problem not having been recognized

Written record and litigation Medical/dental records are the single most important source of evidence in a lawsuit Usually more reliable than testimony based upon memory Especially helpful if it corroborates the oral testimony

How to handle errors Do not obliterate, white- out, or erase any entry; this can give the impression that the dentist had something to hide or that something was done wrong Use a single line drawn through the entry and then write in the correct information; write “error” and initial the correction amalgamcomposite

What not to include in notes Anything not related to patient care Documentation regarding any discussions with your attorney or liability carrier Personal comments on a patient’s characteristics Critical or subjective comments about the patient Conclusions or diagnoses that you are not qualified to make Statements critical of a previous dentist Comments related to the patient’s financial information that could be interpreted as compromising care

Evidence of noncompliance Document a patient’s failure or refusal to follow your recommendations or directions, e.g. –Consistently poor oral hygiene –Refusal to take medication –Leaving dentures in at night –Requesting narcotics instead of having treatment –Continuing to smoke Document any uncooperativeness in an objective manner Document lateness, missed or failed appointments

Maintenance of records There is no law that stipulates how long patient records should be kept Ideally, records should be kept indefinitely as they are the best defense against a malpractice action that may be brought years after the treatment was provided Applies to the written record as well as radiographs and study models Statutes of limitation may or may not apply; may depend upon when the patient discovered the claimed injury and not when the treatment was rendered Consider storing charts of inactive patients off site

Who owns the dental record? The physical chart, including radiographs, are the property of the dentist The information contained in the record is the property of the patient and thus they are entitled to a copy of their records. The dentist is permitted to charge a reasonable fee for the duplication of the records Since the dental records contain confidential information about a patient, the information contained therein should not be released without the patient’s written authorization The original record should never be released to anyone unless so ordered to do so by the court. Your attorney should be consulted, however, before they are released

Referrals Referrals should be documented Information should include: –Description of problem (why referred) –To whom referred –Statement that patient understood the need for and agreed to referral –Outcome of referral (did patient go? What was the outcome of treatment?)