The Importance of Accurate Clinical Records
Who is responsible for charting and documenting clinical records in your office? Ultimately, it is the dentist who must verify that clinical charting is completed and anesthetics, medicaments and procedures are entered correctly on the paper or in the computer. I work with many different practices and observe many systems for recording data, and I am amazed at the diversity of this system. I see the dental assistant writing up the paper chart in one practice and the dentist doing all the charting in the next practice. Two buildings down the street, the dental assistant is entering the treatment plan into the computer charting system as the dentist calls the procedures from the dental chair. When the chart reaches the front desk or the computer screen at the front, the business staff is assuming that all treatment has been entered so that insurance can be billed and co-payments collected.
Complexities arise when there is double entry in the computer and the paper chart, resulting in errors. “I wrote the FMX in the paper chart but I forgot to write it in the computer chart.” Lack of training on the software charting leads the doctor and the staff to keep using the paper chart to enter information and procedures. The clinical note area in the software is often used but the chart is ignored. Treatment planning is often written on the paper chart and then taken to the front office for the business staff to enter while the patient sits in the reception room waiting. The patient has time to think, “the treatment plan must be quite extensive, how am I going to pay for this?”
Dental offices are busy, patients’ needs must be met and it seems that no one is willing to give up a day or even a few hours for software training so that a better and more accurate system can be developed to please the dental team and the patient. This broken system of double entry is full of errors and omissions and should be eliminated as soon as possible. If the computer software has a clinical charting with perio and the x-ray is digital, now is the time to start going chartless. The team should pick a day and from that point on do not create another paper chart. Scan in paper documents, get a signing pad for documents in the computer and start using the software.
Billing insurance companies improperly can result in an investigation and possible litigation. Creating false claims on purpose to defraud is not the same as carelessness in charting teeth surfaces and procedures incorrectly but it can result in the same investigation. For instance, in Doctor Smith’s practice, Sherry billed for a full porcelain crown on #11. The crown was delivered and the claim was paid. The patient never returned to the practice. Two years later, the patient phoned and said that he had just seen a new dentist and was told that he needed a crown on #11 due to the breakdown of an existing filling. The new dentist had billed his insurance for the new crown and was denied for frequency limitations. The patient was accusing Dr. Smith of filing a false claim.
The insurance company and the patient requested the records of Dr. Smith, including the clinical notes. Dr. Smith took a look at the paper chart and the x-rays and concluded that the dental assistant who had charted the day of the prep had written tooth #11 when it was supposed to have been tooth #6. Consequently, the business staff billed the insurance exactly as it was written on the chart, assuming the accuracy of the clinical staff. The statute of limitations has run out to bill correctly for the crown on #6 and the money had to be returned to the insurance company to be applied to the new crown on #11.
The lesson in this story is that posting charting information to the computer software has been proven to be far more accurate. No longer is the issue of handwriting legibility and spelling a concern. It is a much faster system and because of the standardizing it can help eliminate errors. The charting in the software gives a clear visual of what you are charting and you can set up standard wordings to choose instead of having to write each time. The added bonus of the doctor and the clinical assistant charting together makes it easier for the assistant to ask the doctor to check the computer screen for errors before releasing to the front office.
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