Effective Endodontic Treatment Charting

Effective endodontic charting can really be an asset if an issue arises with a root canal therapy (RCT) procedure. The strength of your defense against allegations of malpractice rests mainly on the quality of your patient records. A well-documented chart not only protects you legally, but also reflects the thoroughness and professionalism of your practice. Let’s examine what a comprehensive endodontic treatment record should include.

Discussing Expectations with the Patient

Unfortunately, RCT can often result in less-than-ideal outcomes. Patients typically consent to the treatment, mistakenly believing that the procedure is guaranteed to succeed. When an untoward complication arises, they may blame the dentist and claim that the treatment did not meet accepted standards of care.

Generally, RCT attempts to retain a tooth that may otherwise require extraction. Although RCT has a high degree of success, its success cannot be guaranteed. Occasionally, a tooth treated with RCT may require additional treatment, surgery, or extraction. Be sure to establish realistic expectations of the procedure with your patient and talk with them about undergoing endodontic therapy. 

What to Include in the Endodontic Treatment Record

Here’s what to document before the procedure:

• The endodontic treatment record should begin by documenting the patient’s subjective complaints, identifying the tooth number to be treated, and detailing the findings that led to the diagnosis, serving as the basis for endodontic treatment.
  
• The chart entry should include but is not limited to, your visual, radiographic, percussion, palpation, and vitality testing findings.
  
• Assess the tooth’s restorability and record your evaluation—performing endodontic therapy on a non-restorable tooth violates the standard of care. Develop a reasonable prognosis and document your discussion of it with the patient.
  
• Obtain the patient’s informed consent by documenting the conversation before they confirm their consent. The record should show that the patient had an opportunity to have all their questions answered regarding the endodontic procedure they are about to undergo.
  
  

Here’s what to document regarding the procedure itself:

• Once treatment has started, identify the specific anesthetic agent and any additional agents used to enhance the patient’s comfort during the procedure – including the name, dosage, injection site, and any unusual reactions.
• The name and amount of any pre-treatment anxiolysis medications prescribed.
• If nitrous oxide is used, provide the percentages specified and confirm that the delivery equipment is functioning properly.
• The chart entry should indicate whether a rubber dam was utilized, and if not, why.
• Obtain and confirm a working length for the canal(s), indicating the method used. Note the type of canal shaping instrument, whether hand or rotary, along with the brand and the final instrument’s diameter.
• Observe the state of the pulpal tissue, such as whether it is necrotic, hyperemic, or similar.
• Identify all irrigants, intra-canal medicaments, and obturation materials utilized.

Here’s what to document after the procedure:

• Obtain high-quality post-treatment X-ray(s) for diagnostic purposes.
• Document any untoward complications during the canals’ cleaning, shaping, and obturation. Inform the patient about any significant complications and how they responded (reacted) to this information. Document referrals needed due to the complication(s).
• When dismissing the patient, provide clear instructions regarding potential emergency complications and the appropriate actions to take if one occurs.
• Ensure prescription medications include clear instructions on how to take the medicine and what adverse reactions may occur.

• Take note of your discussions about the necessity of the tooth’s final restoration and when to move forward with it. 
  
  

Effective Charting to Ensure Your Success

While this may seem like an arduous task, taking prudent and diligent steps to document the endodontic procedure (or any procedure, for that matter) comprehensively will help you defend your treatment if necessary. Not only does it safeguard you against future legal claims, but it also may elevate the quality of care you provide. A well-kept record is a hallmark of a conscientious practitioner—one who communicates effectively, treats responsibly, and stands behind their work.

Root canal therapy may not always go perfectly, but with precise charting and patient-centered communication, you can ensure your practice stands on a solid foundation.

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