Dental Record Keeping 101

by Julian Perez, Director, Regulatory Compliance, dentalcorp

Recording accurate patient information is essential to the practice of dentistry and fundamental to the delivery of quality patient care. The dental record (aka patient chart) is the official source of all diagnostic information, clinical notes, treatment and patient-related communications that occur in the dental office, including instructions for home care, consent to treatment and finances. It provides invaluable data, which can be used to assess the quality of care that has been provided and to properly plan for treatment going forward.

The patient chart is also a means of communication between the treating practitioner and other clinicians who may treat that patient in the future.  Thus, the dental record should contain enough information to allow another provider to understand the patient’s experience in your office.

What should the dental record contain?
First and foremost, the information contained in the patient chart should be clinical, covering all basic patient information, medical history, and interactions with your practice as well as other oral health care professionals. The following is a more in-depth discussion of two aspects of the patient record: progress notes and medical and dental histories.

Progress notes
Progress notes are a critical aspect of the patient’s record. Because they are essential for treatment continuity, progress notes should be completed during or immediately after each visit and must be reviewed and approved by the treating clinician. The level of detail required is both patient and treatment specific; however, all progress notes should contain:

  • The date of treatment
  • A concise but complete description of all services provided
  • The treating clinician’s identity
  • The materials and methods, including the type, amount, and result of any anesthetics used
  • Radiographs exposed and what they revealed
  • All recommendations, advice and any discussions regarding possible complications or outcomes.

Medical and dental histories
To allow for the provision of safe dental care, dental professionals must ensure all necessary and relevant medical information is obtained prior to initiating treatment. Medical and dental histories should be collected in a systematic manner, recording the patient’s present state of health and any serious illnesses, conditions or past adverse reactions that could inform the clinical management.

The patient chart must likewise include a notation of any significant dental history, e.g. an assessment of caries risk and periodontal health. Every patient is unique and the dental history should be considered together with the clinical examination when planning and sequencing of dental care.

Additional aspects of the patient chart to consider and watch for:

Records and third-party payors
Dental records are also evidence of the work performed and could be necessary to get paid (e.g. by insurance companies). If the chart doesn’t justify the claim submitted, an insurance company might refuse payment or demand reimbursement. This will certainly lead to an upset patient, and if there is a serious discrepancy between the progress notes and the bill submitted, fraud might be suspected. In these situations, insurance companies could audit your records or even report you to the College. Keeping good records helps avoid this unnecessary stress. For example:

  • The date the service was provided and the code must align with the treatment recorded
  • A complicated extraction is not something that was difficult, rather it indicates a flap was raised and/or the tooth was sectioned
  • A PFM crown must have a lab receipt that confirms the materials used. If you provide a Zirconoia crown and accidentally submit the code for a PFM, you might be accused of insurance fraud or overbilling.

Never, never retroactively alter the patient chart.
To avoid allegations of tampering, errors or incorrect information should never be erased or eliminated from the chart. Instead they should be struck out in such a way that the original notation is still readable. Electronic records must leave an audit trail that accomplishes the same result. Late entries should be clearly marked as such. In no circumstances should a clinician add to or correct a patient’s chart after receiving a demand for compensation or notice of legal proceedings. Any changes made against that backdrop would be perceived as self-serving, perhaps even fraudulent.

What do I have to give patients when they request their “chart”?
Patients are legally entitled to access their complete dental records and upon request, the dental office must provide the patient with a copy of all requested records in a timely fashion. This includes records prepared by other doctors that the dentist may have received. Whether you are providing the records directly to the patient or transferring them to another clinician, as a general practice, you should not let the original files out of your control. The physical copy of original dental records (if kept in hard copy) is the property of the health care provider that created it.

How long do we have to keep dental records?
In general, clinical and financial records, as well as radiographs, consultation reports, and drug and lab prescriptions must be maintained for at least ten years after the date of the last entry in the patient’s record. In the case of a minor, these records must be kept for at least ten years after the day on which the patient reached the age of eighteen years.

When things go wrong, good records are your best friend.
Beyond patient care, the dental record is important because it may be used as evidence in court or in a regulatory action to establish the diagnostic analysis that was performed and what treatment was rendered to the patient.  A quality dental record can be used to respond to a patient complaint, in defense of allegations of malpractice, or to justify treatment in case of an audit by a third-party payor. In all these scenarios, information found in the record will help demonstrate that the diagnosis and treatment were reasonable and conformed to the relevant standards of care. If the patient chart is sparse or non-existent, the decision maker will be left to assess the credibility of the parties, knowing that the clinician was negligent (at the very least) in his or her record keeping duties.