Recordkeeping - What Do We Need?
Patient records are the backbone of a dental practice. Without detailed records we lack a format for comprehensive treatment and sequencing, as well as the legal documentation needed in the case of a malpractice suit, or demand for refunds from an insurance carrier on grounds of utilization review findings. Without detailed records, chaotic planning can occur. What happened at the patient’s last appointment impacts what is going to happen today. If not described accurately, mistakes on today’s services may be made. We cannot rely on a staff person’s memory of whether or not the patient was pre-medicated at their last visit or had an untoward reaction to an anesthetic. Even in the absence of a possibly serious consideration such as these, lack of coherent records can make an office appear unprofessional.
Paper records are disappearing in favor of computerized formats. Patients expect their dentists to be up-to-date. While they may value old-fashioned concern and care for their treatment needs, they do not value old-fashioned systems. With this in mind, what do we need for accurate recordkeeping? How can we document our patients' appointments to include what is necessary in a reasonable and organized fashion?
Many computer record formats allow a template for notes, with headings appearing and staff filling in the documentation. Some allow for “pre-packaged” notes that provide a “canned” entry that will be correct the majority of the time, perhaps with a slight modification. Some are completely free-form with all notes needing to be generated at the time. Offices need to be careful that if pre-packaged notes or headings are used, today’s entries must be totally accurate for this patient’s treatment. For example, if a canned entry is used for local anesthetic because the dentist uses the same type most of the time, be sure the entry reflects how many carpules and the type of injection. It would not do to have #3 MOD, #4 MOD and #5 MOD listed with a canned entry for each tooth of two carpules of anesthetic. This would mean the patient is documented as receiving six carpules for treatment that likely was completed with only two or fewer. The problem associated with this is obvious. As an example, let’s look at a “heading style” format for documentation for an adult hygiene appointment.
MH (Medical History): A patient’s medical history should be updated no less than once annually. This means going over what the patient had listed at their last update and documenting anything that has changed. The medical history notes need to contain today’s date and the initials or other identification of who is making the entries. The patient may be asked, “Have you had any changes in your health or medications since your last appointment?” This is a good beginning, but often it is helpful to also ask for specific changes such as, “Are you taking any medications for bone-strengthening or have you had any surgery for your heart or joints?” Implications for oral and general health related to these questions are important, which patients may not realize.
DH (Dental History): Note if the patient has a concern today, or if treatment was not completed or is pending since their last appointment.
OCS (Oral Cancer Screening): Note the fact that a screening was accomplished and what was revealed.
RAD (Radiographs): List radiographs taken and give the reason. It is no longer considered appropriate to take x-rays “because we always take them once a year.” In addition, ADA guidelines tell us that radiographs need to be ordered by the dentist. For example, “Four BWs taken as per Dr. Smith to check for interproximal decay.”
PHOTOS: List any photographs taken today and why. “Photo taken of #3 crack on DL cusp.”
PERIO: Describe the patient’s condition today. Generally healthy, gingivitis, etc. Document probing depths (at least once a year) on a separate screen. List bleeding on probing, furcations, mobility and recession as appropriate.
HYG: Note assessment and procedures completed. For example, “Moderate plaque and calculus. Ultrasonic and hand instruments used. Polished and flossed all areas including under lingual fixed retainer #22-#27. Reviewed brushing and use of rubber tip in the patient’s mouth and in the mirror. Gave new brush, floss and rubber tip. Recommend 3X a year prophys due to calculus build-up.”
DENTAL: “Recall exam with Dr. Smith. #3 has existing inadequate MOD amalgam restoration with crack on DL cusp. Recommended full crown.”
NV: Next visit, 1 hour for crown prep #3
RECALL: 4 months. Appointment made for Sept. 30, 2013, 10am with Carol
Anyone reading these notes will have a complete and accurate picture of what the patient presented with today, what treatment was provided, and what the next step will be in this patient’s care. In addition, the person filing insurance knows what surfaces are involved with the crown needed for #3 as well as the fact that a crack is apparent. A photo, which was taken today as documentation, can also be included. The insurance coordinator doesn’t have to search through all the radiographs and photos in the patient record, s/he knows a photo was part of today’s appointment because of the detailed patient notes.
If there is ever a question about the appropriateness of the #3 crown, these notes will derail any endeavor by an insurance carrier for a utilization-review based refund. And if a malpractice problem occurs due to any unforeseen circumstance, these notes will back up the dentist and hygienist’s treatment.
Recordkeeping is not glamorous or exciting, but it is essential. Our computerized formats make it easier than ever. Taking the time to do it right is an important facet of dental care in today’s modern world.
Carol Tekavec RDH is the Director of Hygiene for McKenzie Management. Carol can improve your hygiene department in just one day of training “in your office.” Interested in knowing more about how to improve your hygiene department? Email firstname.lastname@example.org.
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