Dental Records 101: Best Practices for Creating & Keeping Dental Records

Dental charting is a time – consuming and tedious task that may be tempting to skirt when rushing. But it’s important for all dental professionals to understand that there is no case where comprehensive and detailed record keeping is overkill. Even the most basic data collected during a dental exam is critical to the outcome of a patient’s testing and treatment. Plus, all records – including Electronic Health Records (EHR) – will be important if the patient ever makes a claim of dental negligence or malpractice.

Below we discuss the leading best practices for dental recordkeeping and have industry experts weigh in.

What’s Included in Most Patient Dental Records?

A patient’s dental record is a living document chronicling the oral healthcare that follows the patient throughout their lifetime. Dental or other medical professionals add to a patient’s record whenever the patient receives care. The American Dental Association (ADA) reports that a patient’s dental chart typically includes:

• Name, birthdate, Social Security number, address, and telephone number
• Health history
• Allergies
• Medications
• Diagnostic test results
• Clinical notes
• Progress notes
• Treatment plans
• Consent to treatment
• Signed forms
• Financial ledger

The ADA standards for dental recordkeeping are easy to follow and can help you protect your patients and your practice by providing a true, accurate, and consistent medical record of your patient’s care.

Here are some things that the Association also suggests not charting:

• Personal opinions
• Informal staff notes
• Disparaging comments
• Financial status

The ADA provides more detail, saying that while it may be appropriate to record the refusal of treatment, hostility, and repeated cancellations, it’s important to know that disparaging or unprofessional remarks will have to be shared in the event a patient files a lawsuit. This might potentially reflect badly on your practice, so it’s best to use neutral or positive statements when charting regardless of the situation.

John Glaser, an executive in residence at Harvard Medical School and a lecturer at the University of Pennsylvania’s Wharton School, paints a vivid picture for the Harvard Business Review of how accurately charted medical and dental records can provide a complete clinical view of a patient’s whole – body health and helps providers offer consistent and accurate care.

“When a patient presents at a [hospital], the care team can use the [patient’s chart] to retrieve patient data from other care settings,” he says. For example, an ER physician treating a patient with blunt force trauma to the face can access the patient’s most recent dental records in order to make informed decisions about their care.

Legal Requirements for Dental Records

The Dental Asssisting National Board (DANB) reports that each state has a dental practice act that may include specific requirements for charting a patient’s dental records. In the absence of guidelines that directly address dental care providers, oral health practitioners must revert to regulations or laws that apply to all healthcare providers. You can obtain information about any recordkeeping requirements that are specific to your state by checking with the state dental society or your state’s board of dentistry or board of dental examiners.

How Long Should Dentists Keep Dental Records?

How long to keep dental records depends on the age of the patient. In general, the ADA suggests that all written records and images must be kept for a minimum of 6 years following the patient’s last date of service. If the patient is under the age of 18, a provider must keep their chart for an amount of time following the patient’s 18th birthday that is decided by the state.

What Is the Legal Liability Associated With Patient Dental Records?

The American Dental Association (ADA) stresses the importance of good dental recordkeeping. The goal: When reading the notes you take on a patient, any other dental or healthcare professional should be able to form a complete clinical picture of the patient, even if that professional has no previous knowledge of the patient or their medical history, the Association says.

But thorough charting doesn’t just benefit patients. It also protects you if legal claims are brought against you. Consider how many patients you see in one day, week and month. If one person comes back claiming you gave inadequate advice or neglected a treatment, your detailed dental notes will help you remember the course of care. Comprehensive patient records track any tests and treatments rendered to the patient and why, and can be useful in a critique of the patient’s care.

“This information is sometimes needed in a court of law in defense against allegations of malpractice,” says the Association’s spokesperson. If medical records are poorly kept, they may be used against dental providers in a malpractice claim or licensure review.

The Dangers of Altering Dental Records

When reviewing a patient’s chart, you may notice that records are incomplete or inaccurate. It’s important that you leave them as is for two reasons. Not only do doctored medical records put you at risk if you are ever the subject of a lawsuit, more importantly, it creates an inconsistent patient record that may compromise the patient’s health and medical care.

Mitchell J. Gardiner, DMD, a private practitioner in Fair Haven, NJ, warns Inside Dentistry of the ramifications of altering patient records. For example, dentists accused of malpractice might discover that the patient’s records are inaccurate, incomplete, or otherwise inadequate. This is when dentists often “add documentation to the record or fraudulently alter the patient record,” he says.

It’s important that patient records are consistent for both the protection of your practice and the benefit of the patient.

HIPAA & Dental Records

The Health Insurance Portability & Accountability Act of 1996 is designed to protect patient data and private health information (PHI). According to HIPAA compliance news outlet HIPAA Journal, the following rules apply to dentists:

• Privacy Rule (2003): Establishes minimum Federal standards of data security for Protected Health Information (PHI)
• Security Rule (2005): Governs the protection of Electronic Health Records (EHR)
• Breach Notification Rule (2009): Requires practices to inform patients of data breaches that have compromised their PHI

“Dentists and Dental Offices should also ensure they are familiar with any relevant changes to these Rules enacted in the HITECH Act (2009) and Final Omnibus Rule (2013),” the organization advises.

Failure to maintain compliance with HIPAA guidelines can result in hefty fines. According to HIPPA Journal, the cost of violating HIPAA can result in up to a $50,000 fine per violation per calendar year. The minimum fine per violation is $100.

How to Create Good Dental Records

Training yourself and your staff to chart appropriately from the start is an important part of providing quality care to patients. Enforcing regular training sessions can ensure your staff creates and maintains good dental records for each patient.

The ADA suggests using the SOAP acronym, which stands for Subjective, Objective, Assessment, and Plan. Using this approach can help guide comprehensive dental recordkeeping while still allowing you to chart important individual details.

• Subjective: Chart the patient’s medical history and any symptoms they are experiencing.
• Objective: Chart your objective assessment of the patient’s condition, including in – office diagnostic test results.
• Assessment: Make a definitive diagnosis for each patient and chart the appropriate billing and insurance codes.
• Plan: Chart your recommended treatment plan for each patient. Be sure to note if a patient refuses treatment and why.

Additional Resources

ADA Dental Record Templates

Prewritten entries – also called templates – can be used to help make charting faster and easier. But the ADA suggests being careful when using template answers, saying that “copying entries from one patient’s [dental] records and pasting them into another [patient’s chart] can put a practice at risk.” It’s more likely that incorrect or generic information will be left in the template answers, which cannot be changed after the fact.

If your dental practice is audited and your patient records include multiple instances of the same generic statement with no customization between patients, it could land you in hot water. If you do use templates, you should ensure they are tailored to reflect your patient’s current condition. Or, use templates that provide structure but require you to fill in the blanks.

Examples of Customized Notes

• I was present in the exam room when [Provider’s Name] [describe the service rendered to the patient]. During the exam, [Provider’s Name] found [describe findings]. Patient was advised of the following treatment recommendations: [describe treatment plan].
• I was present in the exam room when [Patient’s Name] was provided with a detailed treatment plan for [describe conditions and/or treatment plan]. The patient declined to book further appointments at our facility at time of service.

Alternatively, the provider can chart in first person:

• I examined [Patient’s Name] on [Date] and found [describe findings]. Patient was advised of the following treatment recommendations: [describe note findings and or the treatment plan as appropriate).
• I advised [Patient’s Name] that the best treatment for [describe conditions] was [describe treatment plan]. The patient declined to book treatment at our facility at the time of service.

Dental Recordkeeping Continuing Education (CE) Courses

The following are links to some of the most comprehensive dental recordkeeping continuing education (CE) courses currently available online:

• Dental Records: Best Practices for Information Management and Retention by Crest and Oral B
• Risk Management: Prevention of Medical Errors in the Dental Practice by the Academy of Dental Learning & OSHA Training (ADL)
• Electronic Health Records Management by The University of Texas Rio Grande Valley
• EHR for Meaningful Use by the U.S. Department of Health and Human Services, Indian Health Service

Final Thoughts

Accurate and thorough dental records are just as important for the health and well – being of the patients you see as they are for the legal protection of your dental practice. The above tips and resources can help your practice streamline dental recordkeeping by creating a standard method for charting across your practice, and will ensure that you are following the industry’s best practices for dental records.

 

Image courtesy of istock.com/fotofrog

 

Last updated on Jul 24, 2024.
Originally published on Aug 25, 2022.

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