Prevention is worth a pound of cure. As dental professionals, we preach the values of preventive care and regular dental visits. However, within our practices, we often fall short when it comes to providing preventive care for our vital systems.
One of the most critical systems in patient care is the creation of proper documentation for the patient record or chart. An ongoing problem in dentistry is that far too many practices are disciplined or subjected to malpractice due to inadequate patient records. They do not take the time to document patient encounters accurately and thoroughly.
It isn't what is written in the patient chart that is the problem -- it's what isn't written. If it isn't documented or written, it didn't happen.
For instance, the treating dentist or team member might write "exam" in the treatment line and choose code D0120 without recording the description of what was seen and diagnosed during the evaluation.
The purpose of D0120 is to determine any changes in the patient's dental and medical health since the previous oral evaluation. The ADA revised this code in 2021 to include an oral cancer evaluation (OCE). The performance of the OCE and any findings must be recorded in the clinical notes.
Many practices charge out the code D0120 because the insurance plan will cover it without the complete examination that the patient needs to stay healthy. Many insurance payers know this and now ask for clinical notes with claims to support the billed treatment.
10 tips for proper documentation
The sad part is that with today's technology, incomplete records should not occur. It is elementary to get into the habit of creating sound, accurate, and legal patient records, but you must be accountable for your actions to develop these critical records.
Most modern dental practices are equipped with up-to-date computer technology and employ practice management software that allows the recording of patient data and clinical documentation of each patient encounter. But some practices still maintain paper and computer charts, which can cause double entry and incomplete records on either the paper chart or the computer chart.
It's never too late to create better clinical records to prevent adverse outcomes from insurance payers or malpractice attorneys.
To ensure that you include all of the elements necessary to create a chart note, take the following steps:
Thoroughly document recommended treatment before rendering the treatment. Cite reasons for ordering radiographs and intra- or extraoral photos, as well as reasons for ordering diagnostic casts or other tests. Record the results of radiographs and images with a diagnosis of conditions and recommended treatment. Write the clinical findings for all tests in the chart.
Check to see that all entries are legible and written without unknown acronyms or poor grammar. Paper charts don't "white-out" entries. Put a line through and write the correction underneath, and sign and date it.
See that all patients get a treatment plan, even if it's for just one sealant. When you create a treatment plan, it is part of the record in the computer. A report can then be generated showing all treatment diagnosed and treatment not scheduled.
Update health history at every encounter. The history should be recorded in a digital or written format and signed by the patient.
Document informed consent in the chart, signed by the patient or guardian. Informed refusal should also be documented in the chart and signed by the patient or guardian.
Use the SOAP format to create clinical notes for each patient. SOAP is an acronym for subjective (patient's symptoms), objective (what the clinician sees), assessment (the diagnosis and course of treatment), and plan (what the team performed today and the plan for future treatment). Document assessment/diagnosis in clinical notes, not just treatment rendered.
Document any prescribed drugs or any drugs administered in the practice. Include dosage and refills, if any, in the documentation.
Record referrals to specialists outside of the practice. Also note the methods of follow-up of the patient.
Record essential communication in the clinical chart. This includes conversations, texts, teleconference meetings, and phone calls, as well as a description of the nature and results of the communication.
Do not record made up clinical data. The clinical notes made by the dentist, dental assistant, or hygienist are used to create narratives for dental claims. It is fraudulent to "make up" clinical data to get the claim paid. The clinical notes should include a diagnosis for each tooth that requires treatment.