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in pediatric dentistry volume 23, number 4, december 2014
practice management and marketing news
• Informedconsents.• Treatmentfindings/diagnosis.• Progressnotes.• Allcorrespondence.• Consultations.• Appointmenthistory.
• Dateofvisit.• Reasonsfortheappointment.• SOAPnotes(anacronymforsubjective,
objective,assessment,andplan).• Reviewofdentalandmedicalinformation.• Chiefreasonforthevisitorcomplaint.• Symptoms.• Doctor’sfindingsbothvisibleand
comprehensive.
• Generalcharting.• Doctor’snotes.• Referralinformation.• Initialintakepatientrecord.• Patientmedicalanddentalhistory.• Comprehensiveexamination.
Thorough Documentation Equals Financial Security
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Proper patient record documentation is an essential component to quality healthcare and practice success. The more documentation the better when it comes tosecuring your financial stability with state and federally funded programs. Patientrecords are legal documents that can be a significant contributing factor in favorableor unfavorable legal judgments against health care professionals. The rules arechanging; budget cuts have taken a toll on state and federally funded dental pro-grams for children. It appears that states are looking for newways to supplement theirreduced budgets. Unfortunately, thismay put pediatric dental offices at a high risk for chart audits.
In several states, dentists who areMedicaid providers are experiencing audits and have been askedto refund the program thousands of dollarswhere proper documentationwas not found towarrant theservices performed. Specifically, the independent auditors hired by the state are looking for patientswhocame in before the standard six-month time frame for their recare visit without documentation as towhy they needed the visit prior to the six-month limit.Another red flag is performing serviceswithouttaking the necessary dentalX-rays that show the evidenceof dental diease to support the recommendedtreatment. Be sure your team is following best practices in their documentation of all patient interactions.
• Diagnosticrecords.• Recommendedtreatment.• Discussionofalternativetreatment.• Prosandconsforalltreatment.• Courseofactionaccepted.• Consentsunderstoodandsigned.• Detailsofalltreatmentrendered.• Nextvisit.• Healthcareprovider’ssignaturedocumenting
thetreatment.
Chart records should include the following:
Elements of record keeping for dental professionals:
In addition to the above, an accurate patient accounting ledger and account infomation is vitaltothesuccessofthepractice.
The documentation process is designed to providemedical anddental history, status of a patient’scurrent dental health, recommended treatment, and all communication that takes place betweentheofficeandthepatientorparent.
in pediatric dentistry volume 23, number 4, december 2014
practice management and marketing news
What to know about patient documentation
1. Do not ever alter a chart. Oneofthetopreasonshealthcare professionals lose malpractice cases is that thechartwas found to be altered.When a doctor tries toinsert additional comments andmake them appear ascontemporaneous to the original entry, it can be dis-covered. There are ways to determine in softwaresystems as well as hand written charts when entrieswere made. It is also fairly simple to determine theage of the ink itself and if two different pens wereused.Once a chart is discovered to have been altered,the health care professional loses all credibility and isoften found inmalpractice. If an entry needs amend-ing, it is best to write an addendum that refers backtotheoriginalentry.
2. If something is not recorded in the chart, it never happened. Health care professionals have an ethicalandlegalobligationtorecordallpatientinformationinthe chart. If the chart is notwritten correctly by staff,it is the responsibility of the health care professionalto educate staff and correct inaccuracies prior to thecompletion of the chart note. Forgetfulness is not adesirabletraitwhenitcomestodocumentation.
3. Just the facts please. Patient charts require fact-basedinformationandshouldnotbe subject to theopinionsor interpretation of others. For instance, “Patient wasupset with our office because of the issues with thistooth.”Insteadwrite,“Patientstatedthathertoothwasstillbotheringheraftertwoweeksandshestillcouldn’tchew on the left side.” Another example: “Patient ap-pearedfineandwasreleasedtomomanddad,”shouldbe written as “Patient’s O2 levels were normal, thebleeding has stopped and patient was alert. Releasedto the care of the parents. Post-operative instructionswere given to mom.” Remember that you are trainedin your specific health care specialty and are not tomake judgments or guesses outside of your realm ofexpertise.
4. Handwritten documentation must be legible. Al-though people often make fun of doctor’s handwrit-ing, it isessential thatall recordentriesarecompletelylegible. You may understand what you are saying butunless everyone can read the same thing from yourdocumentationitcancauseacriticalerror.
5. Written chart notes. Do not skip lines or leave whitespaces. Also, do not write in the margins or try toshove in your documentation below the last line. Al-ways use permanent ink and do not ever use a whiteoutor error corrector.Whenanerror ismade, simplydraw one line through the entry andwrite, ‘last entrywas written in error. The correct entry is as follows.’
6. Remember your timeline of events. Accurate docu-mentationrequiresatimelineofeventsastheyhappen.Do not state that you injected the patient with anes-thesia and then reviewed the medical history. It iscrucial that each step is documented in the order itwasperformed.
7. Every material used and the amounts need to be documented. It isnot enough to state that thepatientwas given N2O and injected with local anesthesia.All percents ofN2Oand lengthof timeonN2Oalongwith the type and amount of anesthesia is required. Document types ofmaterials and amountswhen-ever possible and all steps involved. It is not enoughto state that a resin-bonded filling was placed whenthere are several other factors involved;make sure allthe steps (etch, isolation, bond, etc.) are all present inthenotesaswellastheshadeandmaterialsused.
8. Leave out personal comments. Since thepatientchartis a legal document you should never write thingslike ‘patient is always late,’ ‘highmaintenance patient,’‘PITA patient,’ or ‘patient has helicopter parents’ inthe chart. Remember: Just the facts. (e.g. “Patientwaslate for their appointment; this is the fourth docu-mented occurrence that the patientwasmore than 10minuteslatetotheirappointment.”)
9. Be careful with abbreviations. Although many risk-managementcompaniesfrownuponusingabbreviations,many dentists still use them in their documentation.Caution shouldbeused if you intend toutilize abbre-viations. Everyone must remain consistent with theiruseandithastobeanallornothingapproach.Whenclinicians sign charts and use their initials, theymustkeep on file what initials belong to whom. It may bedifficultfiveyearsfromnowtorememberanassistantthatworkedforyouforonlytwoweeksthatusedtheinitialsJM.Also, no two clinicians should be using the sameinitials in the chart. It must always be clear who
in pediatric dentistry volume 23, number 4, december 2014
practice management and marketing news
“Accuracy of statement is one of the first elements of truth; inaccuracy is a near kin to falsehood.”
~ Tyron Edwards
wrote what and who performed the services in casethatpersonisquestioned.
10. Each person who performs services should be record-ed in the chart. Many times there aremultiplepeoplewho work on a patient. One person took the X-rays,another person reviewed the medical history withmom, andmaybe a third person actually polished theteeth. Each provider should be documented. If thepersonwho took theX-rays signs the chart for all theprocedures but she isn’t coronal polish certified itwilllook as if she was working outside of her realm ofexpertise and therefore causing the office to benoncompliant.
11. If there is a potential malpractice issue, you will not know about it for a while. Many timesoffices arenotnotifiedofanymalpracticeclaimsorother issuesuntil
monthslater.Donotexpecttorememberallthedetailsofapatientvisit.Keepyourdocumentationinthechartprofessionalandwithin thestandardofcare.However,ifyouhaveapatientorparent interactionthatyouareconcernedabout,youcanalsokeepajournalofevents.For instance, “Dad declared that hewas unhappy thathe didn’t realize that the crownswere going to be sil-verandhe isupset.”Talk toeachmemberof the teamthathadcontactwithdadandhavethemwriteastate-ment for your records. Contact your liability insur-ance and explain the situation and take their advice.Often times a proactivemeasure is your best defense.
12. Remember, patient records are your responsibility. It is not your employee’s practice or license that isliable, it is yours. Inaccurate or missing informationcanmakeorbreakahealthcareprofessional.
Published four times per year as a direct membership benefit by the American Academy of Pediatric Dentistry (AAPD), 211 East Chicago Avenue, Suite 1600, Chicago, IL 60611-2637, (312) 337-2169. Copyright2014 by the AAPD. All rights reserved. ISSN 1064-1203. aapdinfo@ aapd.org, www.aapd.org. Writer: Julie Weir has built an outstanding reputation as a consultant, interna- tional speaker and author in the business of dentis- try. Opinions and recommendations are those of the author and should not be considered AAPD policy. Chief executive officer: Dr. John S. Rutkauskas; Publications Director: Cindy Hansen; and Publications Manager: Adriana Loaiza.
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american academy of pediatric dentistry 211 east chicago avenue, suite 1600,
chicago, illinois 60611-2637
