What and How to Write, or Change, in the Dental Record

Guidelines for Practice Success | Managing Professional Risks | Patient Records, Charting, and Documentation Protocols

The recording of accurate patient information and treatment in the dental record, sometimes referred to as the patient chart, is essential for good risk management. As a result, the value of maintaining thorough and accurate dental records cannot be overstated.

Some dental practice acts and/or regulations issued by state boards of dentistry have specific requirements for dental records. In many states, patient record keeping requirements may be detailed in laws or regulations that apply to dentists and healthcare professionals and businesses in general or in state legislation and regulations that apply to businesses generally, such as state data security laws. Check with your state dental society for information on record keeping requirements in your state. The dental record is your official document that details all diagnostic information, health history, clinical notes, treatment performed, and patient-related communications that took place in the practice. That’s a key reason why dentistry, and the broader healthcare community, subscribes to the maxim that “if it’s not written down, it didn’t happen.”

The dental record is also a legal document that can be the single most important source of supporting evidence in a liability claim or board of dentistry complaint. In fact, various professional liability companies have reported cases when they could not successfully defend a dentist against unfounded allegations of malpractice because of errors or inadequacies in the patient record. Among those topics representatives of professional liability companies have reported seeing with the greatest frequency include inadequate documentation of dental findings, diagnoses, procedures, treatment plans, medical histories, and the informed consent/refusal process.

While that information is critical to ensuring that the proper patient care has been provided, it can also be used to determine whether the diagnosis and treatment conformed to the standards of care in the community. Refer to the article, The Standard of Care in Dentistry, that’s included in this module for more information. In the event that you’re ever named in a complaint to the state dental board or accused of malpractice, the information in the patient record can influence the outcome.

It’s a good idea to contact your professional liability insurance company and legal counsel to get their recommendations regarding what should be included in the dental record. Most liability carriers offer this information free of charge to policy holders; others may offer limited online access to information and resources to dentists who are not policy holders.

One primary reason for keeping the information in the patient record objective and limited to necessary information about treatment is that the Health Insurance Portability and Accountability Act of 1996 (HIPAA) gives patients the right to review or amend their records and/or have request that dental practices covered by the regulation send copies of their records to another person designated by the patient. The provided records would also include any “personal notes” that may be recorded in a separate location, file or chart. It’s possible that personal notes labeled “attorney-client privilege” that are stored separate from the patient record may be protected from discovery.

Dental practices are considered covered entities if they transmit electronic “covered transactions,” such as electronic claims, to dental plans. It’s also possible to become a covered entity by contracting with an outside service, such as a clearinghouse, to submit electronic covered transactions on behalf of the dental practice.

The dental record also provides a way for you, as the patient’s treating dentist, to communicate with dentists and other healthcare providers who may be involved in managing the patient’s care. Complete and accurate records allow providers who do not know the patient to become familiar with the individual’s dental history and experience while under your care.

Consider these tips before making entries in the dental record:

  • Charting practices should be consistent in each setting and the dentist is always obligated to ensure that charting is accurate.
    • Consider using the SOAP (Subjective, Objective, Assessment, and Plan) method for chart entries. See the article titled Templates, Smart Phrases and SOAP in the ADA Guidelines for Practice Success™ (GPS™) module on Managing Professional Risks for more information.
  • Always think before you make an entry in the dental record, especially if the remarks are complex.
    • Remember, it’s possible that your notes could be read aloud in a court of law. Make certain that they present an accurate picture of what took place. With that in mind, it’s a good rule of thumb to first outline what you plan to communicate in the record and then enter the information into the patient record in an organized manner.
  • It is best to document while the patient is still in the office, or as soon as possible after the patient leaves.
  • Each entry in the dental record should be clearly written and linked to the person making the note.
    • This should be done even if there is only one dentist entering information in the treatment record
    • Most practice management software programs automatically assign the initials of the person making the notation based on the user’s log-in credential. Entries in paper records should be initialed and/or signed by the team member writing the entry. The dentist should sign off on all entries in patient records regardless of the format.
  • Be sure to include any appropriate attachments, such as radiographs and informed consent or informed refusal documents.
    • These attachments provide a resource for the dentist to evaluate the short-term and long-term results of treatment performed and the effects of any complicating factors.
    • They may also provide a reminder of the patient’s response and cooperation.
  • Take care when changing, or adding to, previous notes in the record, especially when doing it around the time that your practice management software system is scheduled to update or close records.
    • Strive to complete treatment notes within 24 hours, since doing so in that timeframe could allow you to respond if you were asked under oath about the timing of any changes that changes to a patient’s record were done “that day” or “on the same day.”
    • Make sure you know when the software closes the “Notes” section of patient records versus when records are closed, typically at the end of the month.
    • The timing of changes, and the types of changes made, can prompt questions regarding whether the record was changed after treatment was performed and if the change was made in an attempt to protect the practice or the treating dentist.
    • Belated chart entries, including any corrections of prior entries, should include the date and time when the belated entry was added.
    • Never alter the record when faced with a dental malpractice claim, board inquiry, and/or patient complaint about the efficacy of treatment you provided.

Just like you protect the practice by having professional liability coverage and access to qualified legal help, you may want to consider hiring an information technology expert to help prevent – or trouble shoot and fix – any technology problems.