The dental record, or patient’s chart, is the official office document that records the treatment done in the dental office.
The dental record also serves to provide continuity of care for the patient and is critical in the event of a malpractice insurance claim. State and federal laws determine how the dental record is handled, how long it is kept, and who may have access to the information.
The information in the dental record should primarily be clinical in nature.
The following are examples of what is typically included in the dental record:
- database information, such as name, birth date, address, and contact information
- place of employment and telephone numbers (home, work, mobile)
- medical and dental histories, notes and updates
- progress and treatment notes
- 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, etc.
The dental record is an extremely useful document. Proper maintenance and security of the information located therein is vital. Review the Dental Records publication below for helpful information regarding records management and additional helpful resources and references.