As we stated previously the purpose of the dental chart is to document a patient’s medical history, describe the conditions requiring treatment, delineate the treatment options given to the patient, and record the treatment rendered details. Your dental records should reflect the high quality of care you give your patients.
When maintaining dental charts, you should NOT do the following:
- Never use “liquid paper” or “white out”. Never scribble over, cut off, or in any other way obliterate a chart entry that has been made.
- Don’t put in a chart subjective comments about the patient – i.e. “Patient is nuts”. Instead, quote the patient’s words – i.e. patient said “I am from outer space”. This will describe the behavior.
- Don’t chart names without describing their function in relation to the patient’s future care such as chart “file separated, unable to seal canal-should see endodontist for file removal and finished rct-referred to John Smith, DDS for file removal.” Not “referred patient to John Smith”.
- It is not necessary to chart information that is not pertinent to the future care of the patient.
- A dental chart should not be filed until it has been checked for completeness.
- Don’t release dental records without obtaining the patient’s written permission (or court order).
- Never alter records after a suit has been filed. Do not correct, clarify, add to, change, or modify an entry in any way.
When maintaining dental records, the patient’s chart should not include:
- Criticism of care given by another dentist.
- Communications with your insurance company or your attorney.
- Communications with the patient’s attorney.
Maintaining accurate dental records is important to risk management.
- Legal actions can take two to three years before they are heard in court making the patient’s chart a reliable record of the patient’s care.
- If a legal action is a nuisance claim, accurate documentation can result in the dismissal of a nuisance claim.
All contents provided here are for informational purposes only. The owner of this blog makes no representations as to the accuracy or completeness of any information on this site or found by following any link on this site. Always consult your legal counselor or advisor as to the suitability of using this information in your business or practice.