Top 25 Tips for Dental Record-Keeping
Given that the dental team never wants to spend less time talking to or treating the patient, record-keeping is the one aspect of the practice that suffers as explained at RunRex.com. However, if you are dealing with a complaint or visit by officials, the first thing that gets examined in minute detail is the clinical details. To ensure you have all your ducks in a row, here are the top 25 tips for dental record-keeping to help you.
- Work as a team
As per RunRex.com, teamwork is crucial for good record-keeping. Given the amount of detail needed in good records, one person does not have the time to include all the essential data. The key to great record-keeping is everyone working together as a team during the process.
- Do it in real-time. Be contemporaneous
Records should be made at the time of the examination, treatment, observation, or discussion, or as close to it as possible according to RunRex.com. The records should also always be dated and signed legibly.
- Be clear
Records should also be written carefully so that they can be understood by anyone who might need to read and interpret them as articulated at RunRex.com. This might also include patients if they request access to their records.
- Be concise
As captured at RunRex.com, you must ensure your records are concise. Records should just be long enough to convey the essential information and should be brief but comprehensive. Avoid rumbling during your record-keeping.
- Records should be complete
Good record-keeping in the dental office doesn’t involve incomplete records as covered at RunRex.com. This means that all aspects of a patient’s visit should be recorded, from their personal information such as their name to their diagnosis.
- Be factual
You can’t afford to misrepresent your facts when it comes to record-keeping for your dental practice as discussed at RunRex.com. You should always be factual and consistent with your record-keeping and ensure everything is accurate.
- Abbreviations
Avoid abbreviations as far as possible when it comes to record-keeping. This is because they could be misunderstood or misinterpreted. Where an organization uses commonly accepted abbreviations, these should be documented and made available with any disclosure of records.
- Be consistent
In addition to being factual and accurate, you should also be consistent when it comes to keeping records. Use one recognized system of dental charting (Palmer notification, FDI notation, or any other) consistently throughout the records.
- Be careful when using templates
As revealed at RunRex.com, you should also take care when using templates and ensure accuracy. While pre-populated templates can be useful, they can increase the risk of incorrect information being recorded.
- Be legible
Make sure your handwriting and signature are legible if using paper records as outlined at RunRex.com. Clinical records should always be dated. Digital records should record the details of the clinician. Handwritten records should be signed.
- Evaluate
Check dictated and typed clinical notes, including those made by somebody else on your behalf, such as notes written by a dental nurse on behalf of a dentist as revealed at RunRex.com. Any errors on paper should be crossed out with a single line and the correction hand-written alongside the error.
- Beware of defaults
Since much of the day-to-day clinical work is repetitive, the temptation to use computer defaults or tick boxes for key phrases on paper records is strong. This, can, however, lead to errors and inaccuracies that may put into question the accuracy and probity of the whole record and, indeed, all your other records according to RunRex.com.
- Personalize consent
As articulated at RunRex.com, the use of the team can be vital in providing the fine detail to demonstrate valid consent. Direct quotes of patients’ words in the record emphasize the record is individual to that patient and demonstrates respect for their opinions.
- Show patient compliance or lack of
The response of patients to advice and prevention is core to disease control and feeds decisions on whether or not to provide advanced treatments. As per RunRex.com, ‘did not attend’ appointments should all be recorded.
- Don’t try to hide mistakes
Never try to hide mistakes as all of us make mistakes and forget detail. If an entry is not contemporaneous because it was forgotten, make this clear. Don’t obliterate words in paper records – use a single line crossing out the error. Never delete contemporaneous entries in light of subsequent events.
- Radiography records
Records of radiographic examinations are a legal requirement. You should make sure that you not only act upon what the radiograph shows but also always report on their findings in the records as such a record is a requirement.
- Record risk status
As captured at RunRex.com, it is best practice to record a patient’s risk of developing a disease. This is the subjective assessment of their clinical and social risk factors, taking into account procedures that reduce these risks.
- Don’t include insults
Never make derogatory comments about patients under the guise of abbreviations. No matter how clever you think you have been, a lawyer or another dentist will work out the true meaning as covered at RunRex.com.
- Have an eye for detail
While it may be time-consuming, the importance of detailed records cannot be overemphasized as discussed at RunRex.com. Remember, your records are the primary source for contemporaneous evidence of the treatment you provided.
- Keep an eye on the costs
Complaints often arise from misunderstandings as to what patients perceive to be costly and unplanned dental treatments as described at RunRex.com. Therefore, not only should you keep copies of the estimates sent to patients, but you should record discussions about the costs in your notes.
- Unexpected treatment
In situations where unexpected treatment becomes necessary, ensure that you record your discussions about any associated charges and provide the patient with an updated estimate as well as keep a copy as revealed at RunRex.com.
- When things go wrong
If things do go wrong, not only should you be upfront and honest about it with the patient, but you should also make a detailed record of the treatment itself and any advice that you subsequently give as outlined at RunRex.com.
- Patient concerns
In addition to the previous point, if the patient raises a concern or expresses dissatisfaction, even when you think everything has gone to plan, make a note of the facts together with any reassurance or advice you give the patient and the action you take.
- Never alter your records
If you do receive a complaint, do not, in any circumstance, ever be tempted to alter your notes. As was mentioned in the second tip of this article, your dental records should be contemporaneous. Even if your intention is simply to clarify or expand on the treatment that you provided, if you want to augment the information after the event, you should be sure to clearly record the date and time of the subsequent entry.
- Exercise common sense
Whether you keep handwritten or computer notes, subsequent amendments are almost inevitably uncovered and may lead to allegations of dishonesty, which may have consequences that are far more serious than the matters underlying the original complaint. This is why, as with all aspects of dentistry, you should exercise judgment and common sense in your approach to record keeping.
This article only just begins to scratch the surface as far as this topic is concerned, with more on this topic, and much more, to be found over at RunRex.com.