The title of this article probably brings up a “duh” or “obviously” comment as we all know documentation and maintaining good dental records are important. However, are you really documenting well enough?
If a situation was brought to light in a court of law would your documentation be enough? If you looked at the notes your assistant wrote would they make sense to you and be adequate?
I was in a situation where I was subpoenaed to testify against another dentist. Thank goodness I document fairly well, but even I learned a few things I could improve on. But I was very glad I wrote my own notes and even wrote notes for hygiene exams!
Because are you going to remember what happened with patient Mr. Smith 1.5 years after he was in for his regular prophy or periodontal maintenance? Especially if you’ve been gone from the practice for over a year? You won’t and you will rely on those notes to remind you of what happened and to have documentation of what happened.
Remember, if it’s not documented, it didn’t happen.
Tips on How To Keep Great Dental Records
So, let’s talk about some keys to documentation:
- Write Your Own Chart Notes
- Write a Note for Exams
- Systematic Notes
- Careful and Thorough
- A Complete Record
- Document all the Facts
- Changing Records
1. Write Your Own Chart Notes
Write or type your own notes! I’m sure some will argue with me on this one but most team members will just use a basic template and not add any notes specific to what was said or done. That’s fine if you want them to start the note and put a template in but I strongly encourage you to go back and fill in the missing pieces because they are there! Remember that ultimately you, the dentist, are responsible for the patient’s chart.
Document your conversation, even using quotations for what the patient said could be priceless in the future, as well as anything discussed whether or not it related to that day’s procedure. Did you discuss post-op recommendations? Did you discuss future treatment or treatment options that the patient decided to ask about that day? Not only is this documented in case the worst-case scenario happens (you end up in court) but also for you to know the next time you see this patient everything that was discussed.
2. Write a Note for Exams
Consider writing a note for the hygiene exam. Yes, I know you have a full schedule and multiple hygiene exams to do within even an hour and I’m asking you to write notes of patients technically not even on your schedule!
But again, most hygienists use a template and don’t add much, if anything, that you as the doc say during the exam. At a minimum, I would suggest reviewing their note and having a conversation with the hygienist about the necessity to document what you discuss as well. So, this goes back to the discussion above for the why as well.
3. Systematic Notes
Have a systematic way of writing up your notes. Doing the above helps you organize your thoughts as well as when you go back to those notes jogs your memory as hopefully, you have a systematic way of writing your notes.
While we are all dentists, we each have our own way our brain works so by writing up your own note, when you go back to that – whether it’s the next patient appointment or heaven forbid you are in court- you can remember your train of thought and recollect what happened during treatment.
4. Careful and Thorough
Careful and thorough documentation is also key. While this may not be true, one may conclude that if your documentation is careless or cursory, your dentistry is substandard also. Having careful and thorough documentation, when it is reviewed displays your quality and competency as a dentist.
5. A Complete Record
Along with being careful and thorough in your documentation, we want it to be complete! A complete record should contain:
- Up-to-date medical history as well as noting that you did review the medical history with the patient
- Diagnosis, possible diagnoses
- Exams, tests, and results
- Imaging done and results of
- Treatment plan
- Documentation of informed consent discussion as well as any consent forms signed
- Medications prescribed
- Next visit or recommended follow-up
- Any other documentation from consults, referrals, or patients’ physicians
6. Document All of the Facts
In documentation in a patient chart, stick to the facts. Remember, anything documented could be brought up in a court of law and the patient record is a legal document. I would suggest that it can be a good idea in some instances to document with quotation marks what a patient does say. Certainly, documenting what is done is necessary but also what is not done as well. Documenting a patient’s lack of compliance, such as refusing to accept recommended treatment, or missing or canceling appointments, is also important.
7. Changing Records
Changing a record should never be done! If you need to make a correction, which certainly does happen, it needs to be done appropriately so as not to appear that you are altering the record. The correction is done via a separate entry and noted as a correction.
Keeping The Best Dental Records Possible
Maintaining thorough, accurate patient dental records is extremely important for many reasons. Complete documentation is key in maintaining this record.
This record helps you provide the best care possible for the patient as it documents the course of treatment. The records also are the way vital information is communicated between providers.
One of the biggest reasons for documentation is in the case of litigations so that your documentation can provide key information to defend you in the allegation of malpractice. We also shouldn’t forget that dental records can aid in the identification of a dead or missing person.
I’m sure we can all agree that talking about documentation is not one of the glamourous parts of practicing dentistry but it is, I would argue, one of the most important aspects of our day-to-day practice of dentistry.
If you do need assistance with your documentation and patient records you can reach out to your state dental society. Some dental practice acts (issued by state boards) have certain requirements as well which you can obtain by contacting your state board at www.aadexam.org or http://ebusiness.ada.org/mystate.aspx.
Consulting with your professional liability insurance company is also another resource to be sure your documentation is top-notch.
Links that helped for the importance of documentation for every dentist blog
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