A key component of establishing proper office procedures is developing documentation guidelines for your practice. A well-documented dental chart is critical to quality patient care as well as the successful defense against malpractice suits. As dental care becomes more complex, documentation that is clear, concise, complete, accurate, and legible is especially critical. There are many examples of lawsuits that would be defensible from a care standpoint; however, the record is inadequate or incomplete. In addition to excellent communication skills, good documentation skills are one of the most important traits a dental professional can develop.Manual v. Electronic Records - Click for more
The healthcare industry has been actively converting from paper or manual charts to electronic record-keeping over the past several years. This massive conversion process and the continuous improvement of technology and software have resulted in the improvement and availability of electronic record system software for dental practices.
Electronic records create their own set of challenges, including how to handle documenting a patient’s signature for a consent form or medical history update or other typically manual processes. It is critically important to capture the paper image in the electronic record with the most common practice to scan the image into the record. Modern software likely includes an electronic signature pad which can be used to electronically transfer your patient’s signature into the record.
The patient’s dental chart should reflect a credible history of treatment rendered as well as the patient’s level of satisfaction. It should include enough information that another dentist would understand the treatment provided, be able to plan the next steps and why the choices were made. Another dentist should be able to maintain the continuity of the patient’s care. Everyone in your practice should be required to follow your established charting guidelines.
Whether your practice uses manual or electronic charting, the following guidelines should be considered when documenting your policies for dental records:
- Document objectively, specifically and consistently, avoiding general statements, humor, assumptions, or bias.
- Document the PARQ (Procedure, Alternative, Risks and Questions) discussion with the patient
- Don’t leave blank spaces, don’t write in the margins and don’t use sticky notes.
- The chart should be in chronological order and each page should at a minimum include the patient’s full name, date of birth and any medication alerts.
- Require an annual written health history update including patient signature.
- Document complaints or issues, including clinical interventions, advice and patient response.
- Document when patients are notified regarding test results and consultant opinions. Include all the details of notification, including date, method, information reported and the person reporting.
- Ensure the appointment schedule and chart date match. Chart all cancellations, no-shows, regular and emergency appointments, re-schedules and cancellations.
- Be specific when documenting referrals to a specialist, including the date, specialist name and specialty and the reason for the referral.
- Meticulously document drug names, doses, routes and regimens.
- Positive and negative findings and patient comments should be included in the record.
When there is an error in the chart, correct the error in a manual chart by drawing a single line through the error and dating and signing the correction. Any omitted information should be added as an addendum or late entry, including the date and signature. Corrections to an electronic record system should be entered as a correction or addendum on the record/progress notes with the date and staff member’s name that made the change.
Electronic data cannot be erased, therefore you should never, ever attempt to alter, change or adulterate an electronic record (or manual record!). Corrections of this nature are almost always detectable on the storage media.
The required content of a patient’s record may vary by state. Guidelines are available through the state dental association. At a minimum, patient’s records should include the following:
- All clinical and financial records
- Date of treatment and provider
- Physical examination findings, including an assessment or diagnosis of the patient’s condition
- Treatment plan
- Dental and medical history that may affect dental treatment
- Any diagnostic aid used including images, radiographs and test results
- Complete description of all treatment/procedures administered
- Record of any medication(s) administered, prescribed or dispensed
- Referrals and any communication to/from any health care provider
- Informed consent
- Post-treatment instructions
Additional safeguards are required when using an electronic record system. Your system should include hardware and software protection. Additional safety measures include data encryption, redundant back-up systems, fraud protection program and password policy. One of the simplest methods of protecting patient information in an electronic record system is an enforced password policy.
Require your staff members to type their name at the end of each entry and document the review of your staff members’ entries by typing your name. Back-up your data daily, keep a back-up disk off-site and conduct occasional audits and tests to ensure your back-up is working properly.
|· Require passwords to be changed at least every 90 days. Use an automatic password “timer” to ensure the policy is followed.
· Design your password policy to include complexity, which requires the use of certain characters, numbers or letters and a minimum length.
· Do not permit the use of past passwords or obvious passwords.
· Immediately de-activate the password of a terminated employee.
Retention/Destruction of Dental Records - Click for more
The guidelines for record retention under the Health Insurance Portability and Accountability Act (HIPAA) (Section 164.316(b)(2)(i) require that “HIPAA related policies and procedures should be retained for six years.” In the absence of more specific state or other guidance, Health and Human Services (HHS) recommends six years as a minimum guideline for HIPAA record retention.
According to Washington state regulations (WAC 246-817-310), dentists “shall keep readily accessible patient records for at least six years from the date of the last treatment.” Prudent practice management suggests keeping records a minimum of 6 years; in the case of minors, 6 years after reaching the age of 18. If a patient is potentially litigious, keep records indefinitely.
Although the statute of limitations changes and is subject to judicial interpretation, longer record retention is a safer practice. Establishing your practice record retention policy and adhering to your procedures is an important component of good office practice management. Ensure your record retention policy is in compliance with HIPAA guidelines and any state regulations that may apply. Then follow your policy, diligently and consistently.
TIPS FOR RECORD RETENTION POLICY - Click for more
|· Keep all charts a minimum of 6 years; for minors, 6 years after reaching the age of 18.
· When destroying paper charts, use a high-quality, cross-cut shredder. Keep a record of all charts shredded, including name of patient and date.
· If use off-site shredding service, keep receipt of charts shredded, including patient name and date.