Risk management starts with what information you enter into the dental record. The dental record, or patient chart, is the official document that houses all diagnostic information and clinical notes.
Complete information about all treatment performed and the patient-staff communications that have taken place in the dental office, such as instructions for home care and consent to treatment, is included. State and federal laws or regulations and state boards of dentistry determine what information is entered there, how and where it is maintained, what safeguards should be in place to protect the information, how long it should be kept, and who should have access to the information. The dental record also ensures continuity of care for the patient. More information is available in Dental Records, an online publication developed by the ADA’s Council on Dental Practice and Division of Legal Affairs and available free to ADA members.
Information contemporaneously entered into the dental record can oftentimes help you defend yourself if a patient files a malpractice claim against you. While the fear of being sued should not be the primary motivator in determining what information you enter there, ensuring that you record appropriate professional information in each patient’s chart every time is critical to protecting your practice.
The recording of accurate, detailed and legible patient information is essential to dentistry. Diligent and complete record keeping protects patients and the practice by:
- Evidencing that your practice has sought to provide the appropriate professional care for the patient. Patient records document the course of treatment and may provide data that can be used in evaluating the quality of care that has been provided to the patient.
- Serving as a means of communication between the treating dentist and any other doctor who will care for that patient. Complete and accurate records contain enough information to inform another provider who has no prior knowledge of the patient of the patient’s experience in your office.
- Documenting the diagnostic information that was obtained and the treatment that was rendered. This information is sometimes needed in a court of law in defense against allegations of malpractice or in a defense of licensure case. Information found in the record may help determine whether the diagnosis and treatment conformed to the standards of care in the community.
Some dental practice acts or regulations issued by various state boards of dentistry specify requirements for dental records. However, in most cases, patient record keeping requirements are contained in laws or regulations that apply to health care professionals in general and can be found in more generic state legislative/regulations. Check with your state dental association for information on record keeping requirements in your state. To obtain a copy of your state dental practice act, contact either your state’s board of dentistry, also known as the board of dental examiners, or go to ADA.org to find a link to your state. Many states post the dental practice act online, making it easily accessible.
Consult the ADA’s Guidelines for Practice Success™ (GPS™) Managing Professional Risks for additional guidance on risk management issues that should be considered within the dental practice.