1. Virginia Board of Dentistry
RECORDKEEPING -
BEYOND THE REGULATORY REQUIREMENT
Roanoke Valley Dental Society
November 6, 2007

2. Recordkeeping is the foundation for good patient care and good communications about your practice.

3. the practice of dentistry and
Good records support billing practices and demonstrate your knowledge of :
your patient,
the practice of dentistry and
the laws and regulations governing that practice.

4. Dentistry means the evaluation, diagnosis, prevention, and treatment, through surgical, non-surgical or related procedures, of diseases, disorders, and conditions of the oral cavity and the maxillofacial, adjacent and associated structures and their impact on the human body.

5. A complete record will address every aspect of the practice of dentistry:
Evaluation
Diagnosis
Prevention
Treatment
Or explain why it doesn’t

6. What is a record?
Is it the file you have identified as belonging to the patient and only what you put in that file?
Is it each piece of paper or document you create or collect on the patient?

7. Recordkeeping Requirements: the minimum standard
Patient’s name and date of treatment
Updated health history
Diagnosis and treatment rendered

8. 4. List of drugs prescribed, administered, dispensed and the quantity
5. Radiographs
6. Patient financial records
7. Name of dentist and dental hygienist providing service

9. 8. Laboratory work orders Name and address of the lab
Patient’s name or initials or
ID #
Date the order was written
Description of work, including diagrams if needed

10. the type and quality of materials to be used
Signature and address of the dentist
Records must be kept for not less than 3 years following the most recent date of service for the Board.

11. An incomplete record undermines care and communications.
Consider this example of incomplete treatment notes:

12. “18” noted in the TOOTH column No entry in SURFACE column
No entry in SHADE column
No entry in AN column

13. Entry in TREATMENT column: “ All Bond II Amalgam
Core – LTP Fair to poor.
Incomplete Endo.”
Billing statement noted “CORP**02950 Core Buildup, Inc. Pins(#18)

14. What do you think the complaint was?
What do you know?
What do you want to know?
What do you think the complaint was?

15. The complaint was that the dentist billed for a core build up on #18 when he only placed an amalgam filling in a hole in a crown

16. who treated the patient a diagnosis medical history
What the record didn’t include was:
who treated the patient
a diagnosis
medical history
an adequate description of the treatment rendered
x-rays

17. What do you think should have been the outcome of the complaint?

18. A complete patient record
1. Patient identified on each document
2. Reason for visit
Review medical/dental
history
4. Patient’s chief complaint
5. Symptoms

19. 6. Visual findings 7. Diagnostic records brought, needed or taken
8. X-Rays, Digital Images, Pictures
9. Dentist’s examination findings
10. Dentist’s diagnosis
11. Recommended treatment

20. 12. Treatment choices discussed 13. Pt consent for treatment
14. Treatment rendered
15. Drugs administered, dispensed, prescribed
16. Name of dentist, dental hygienist and assistant who provided service

21. 17. Items given to patient 18. Laboratory work orders
19. Financial records

22. Remember, if it is not written down – it did not happen.
Consider this example of a complete treatment note:

23. Pt presented for consult re dental implants
Pt reports having pain, odor and not able to chew on #30, has RC/crown

24. #30 presents with abcess, bone loss, mobility, pocketing, bleeding upon probing, rct, porcelain fused to metal crown

25. Extract 30/graft bone/implant
TX options:
Extract 30/graft bone/implant
Extract 30/graft bone/fixed bridge 29-31/implants

26. Alternatives, fees, estimated insurance and complications were discussed.
Consent obtained

27. Detailed notes regarding the extraction and bone grafting
The record included:
Medical history
Xrays and photos
Detailed notes regarding the extraction and bone grafting
Drugs administered

28. Note of home care instructions and products given to pt
Meds dispensed and prescribed
Appt to check tx
Charges and billing transactions

29. The record did not become an issue in this complaint which was about what the pt agreed to and the actual cost vs the estimate.

30. About those records:
x-rays should be of diagnostic quality and you are required to keep them
Can be stored electronically
paper copies are not required if the record is unalterable

31. You own the record but must provide copies
You must provide itemized billing statements when requested

32. You must give notice by mail and in a newspaper before you transfer records when closing, selling or relocating to current patients

33. Confidentiality must be addressed when disposing of records as well as all other times

34. Board of Dentistry WEB Page
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35. 9960 Mayland Drive, Suite 300 Richmond, VA 23233-1463
Board of Dentistry
9960 Mayland Drive, Suite 300
Richmond, VA
Phone: (804)
Fax: (804)
Complaints: (800)