Accurate and Complete Patient Records

If you’ve been accused of dental malpractice or have been summoned by your State Board of Dentistry to answer for the care you provided to a patient, you know how overwhelming it can be. You may remember how it kept you away from your practice and loved ones, the potential loss of income, and the harm it caused to your reputation. Even if you are confident that you’ve followed the accepted standards of care in treating a patient, you will still need to defend your care.

Maintaining accurate patient records is critical for dentists to protect their reputations. Your memory, while credible, is less reliable than a contemporaneous and detailed dental record. When events are documented in writing, it strongly implies to the fact finder (whether they are a juror, judge, or state board member) that those events occurred. If something is not documented in writing, it may be like it never happened. The dentist’s failure to maintain accurate, detailed, and up-to-date patient records is one of the most common reasons for a plaintiff (patient suing the dentist) or a State Board of Dentistry to be successful in a lawsuit against a dentist.

What to Include in the Patient’s Record

A prudent dentist’s accurate and complete dental record serves multiple purposes. For one, it aids in continuity of care for subsequent treating doctors. However, the most significant importance is that it provides a clear, logical, and concise record of the facts and occurrences that took place during the care and treatment of the patient.

The accurate and contemporaneous treatment record should include, but not be limited to:

1. The reason the patient is seeking care from you. Their chief complaint and motivation. Their  expectations for the outcome of treatment.
2. Diagnostic records, including study models, imaging studies, and clinical photographs.
3. Detailed contemporaneous treatment notes.
   1. Provide details of what treatment was performed and the outcome.
   2. What post-procedure instructions were provided?
   3. The patient’s reactions during and after treatment, especially when it involves cosmetic procedures.¹
4. Treatment plans.²
5. Up to date dental and medical histories.
6. Consent forms and the conversations associated with those forms.
7. Medical consults.
8. Specialist or medical doctor referral forms.
9. The results of any head, neck, and oral cancer screening exams.
10. The results of any occlusal and TMJ exams.
11. Dental laboratory prescriptions.
12. Medications prescribed, dosage, date prescribed, the frequency and length the patient should take it—the diagnosis associated with the prescription.
13. Letters and correspondence with  patients and other healthcare professionals.
14. Patient complaints and their resolution.
15. All missed or broken appointments and their effect on the patient’s oral health.
16. Notations regarding patient compliance with home care or other post-procedure instructions.
17. Doctor and patient remarks.
18. Financial arrangements.
19. Laboratory or other test results.
20. Privacy documentation.
21. Insurance claim-related documentation.

Maintaining an objective, factual, and relevant clinical record of the patient’s care and treatment is important. Avoid subjective evaluations irrelevant to the treatment, such as notes about a patient’s physical appearance or personality. Copied and pasted entries and abbreviations, acronyms, or arcane symbols should be minimized. The record should be separate from financial records, such as a financial ledger. Chart entries must be customized to the patient. The handwritten record should be legible, and each page should have the patient’s name and date of birth. Avoid leaving blank lines between contemporaneous entries; it should be dated if you need to make corrections or add additional notes. If you need to add something later, clearly flag the new entry and state that it is an “addendum to an entry dated 00/00/0000.” If you use electronic health records, ensure they fully comply with HIPAA.

Maintaining an accurate dental record is also critical for a dentist to have as evidence in a malpractice case or an accusation by a regulatory board. No information is too small or insignificant to be included in the dental record. The following outline is valuable for comparing your documentation techniques and ensuring that your patient record satisfies all the necessary components and content.

Medical History

Getting a patient’s medical history is crucial. The patient (or responsible party) should fill out the medical history forms accurately, and the patient and the doctor of record should sign and date them.

When taking a patient’s medical history, the first question to ask is when their doctor conducted their last complete physical exam. If it has been three or more years, it is unlikely that they can provide a current and accurate medical history. In such cases, it is recommended that they get a physical exam before starting treatment, especially if any high-risk procedures are expected.

The medical history is complete if it has been reviewed and discussed by the examining dentist and noted on the patient’s treatment record. The dentist must question the patient about all significant answers, and there should be no unanswered questions on the form.

Examination

When needed, it is crucial to conduct a thorough initial examination for all new patients, including the necessary X-rays (imaging), photographs, and study models. Record all missing, filled, and restored teeth, along with any carious lesions and teeth in disrepair, in the tooth charting section of the patient’s record. Additionally, note the condition of existing bridges and removable prostheses and include the results of a comprehensive soft tissue examination. Furthermore, a complete oral cancer screening examination must be performed and documented in the patient’s record at the initial and recall exams. Lastly, a periodontal screening evaluation will be performed by sampling pocket depth for every patient and conducting a complete probing, if necessary, based on the screening exam results, including an assessment of the patient’s oral hygiene.

Treatment Plan

Many state board regulations require each patient’s chart to have a comprehensive treatment plan. After an oral examination, discuss all appropriate treatment alternatives with the patient and note them in the chart. A form may document the final and all alternative treatment plans with a fee estimate. Once the patient understands the treatment plan and has answered all their questions, the patient and dentist should sign it.

It’s important to discuss the patient’s medical history, treatment plan, financial obligations, and all consents in a language the patient can understand. Minor changes in the treatment plan can be recorded in the patient treatment record, but significant changes may require a new treatment planning form.

Before treatment, the patient’s physician should be contacted, if necessary, based on the history provided by the patient. It is the dentist’s responsibility to understand the consequences of all medications the patient takes. A supplemental health questionnaire for extended treatment plans should be provided every recall or every six months.

Informed Consent/Refusal

Doctors must ask questions to ensure that a patient has provided their consent. The consent form must be signed and dated, with the original copy kept in the patient’s record and a copy given to the patient.

When a patient refuses essential treatment, the patient is asked to sign an informed refusal form. Like the rule of informed consent, the patient must be allowed to discuss the recommended treatment and the effects of refusal with the dentist. It is essential to note in the patient’s chart at the time of the discussion that the patient was informed of the risks, including the risks to their health, if they choose not to accept the recommended treatment. It’s also essential to document that the patient has unequivocally and without condition refused the therapy and identify why the patient refused your advice for a particular course of treatment.

Contemporaneous Treatment Record

It is crucial to keep accurate dental records. If you are not using an electronic record-keeping system, write legibly in ink. Document everything necessary for the patient’s proper care and continuity of care for future practitioners. Treatment descriptions should be detailed and include pre-existing, intra-operative, and postoperative conditions. Mention all materials used, including brand names, devices, medications, and their amounts and dosages. Note all positive and negative findings considered when reaching a diagnosis and record any complications or unusual circumstances that may have occurred. If there were any adverse or unanticipated events or outcomes, inform the patient and document it in the record. Every entry must be signed or initialed and dated by the person making it. If an auxiliary has kept the treatment notes, the treating doctor must review them and sign the entry. All referrals, phone contacts, and specialist discussions should be noted in the record. Never erase, obliterate, or write over any entry. Corrections should be made by a single line cross out (and initialed) or by a separate entry indicating it is amending and  supplementing a prior entry. There should be no notations in the margin or between other notations. If using non-conventional abbreviations, ensure that all staff members use them consistently.

Conclusion

It is always better to practice safely and professionally. However, predicting when any action may be taken against you is impossible. To defend your care when necessary and provide better services to your patients, it’s important to take prudent and correct documentation steps. If you ever receive a malpractice claim or dental board complaint, it is recommended that you immediately “lock down” the record and not alter it in any way, for any reason. This will ensure you have a reliable reference record should the need arise.

1  Contemporaneous notes can be helpful in refuting allegations of buyer’s remorse after a cosmetic procedure.

2  Some of the most common errors in dental records are the lack of a documented treatment plan, no informed consent and/or refusal documentation, the health history is incomplete or has not been updated regularly, and the treatment rendered is not clearly and thoroughly documented.

The information contained on the DentistCare Blog does not establish a standard of care, nor does it constitute legal advice. The information is for general informational purposes only. We encourage all blog visitors to consult with their personal attorneys for legal advice, as specific legal requirements may vary from state to state. Links or references to organizations, websites, or other information is for reference use only and do not constitute the rendering of legal, financial, or other professional advice or recommendations. All information contained on the blog is subject to change.