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Creating Patient Records that Support Your Care and Reduce Your Risks
Welcome Back, Dr. Vaselaney!
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CREATING PATIENT RECORDS THAT SUPPORT YOUR CARE AND REDUCE YOUR RISKS
By John Vaselaney, DDS, ARM; Director of Risk Management
Creating accurate and thorough patient records is an important part of both clinical dentistry and dental risk management. A well-documented patient chart provides for continuity of care for the patient and can be crucial to the dentist’s defense in the event of a dental licensing board complaint or a malpractice claim.
The primary purpose of the patient record is to memorialize information about the patient as well as the dentist’s thoughts and actions in caring for the patient. It’s not possible – and certainly not expected – for a dentist to recall from memory every aspect of every patient’s care from every appointment. That is what the patient record is for and why it’s so important. A good patient record preserves what the dentist heard, saw, thought, said, and did in the course of providing care.
Another purpose of the patient record is to be able to share information, whether with your staff, with other dentists such as specialists or subsequent treaters, or with third party payers through whom patients receive benefits.
Additionally, the patient record is the dentist’s first line of defense in the event of a dental board complaint or a malpractice claim. Even if the dentist has provided excellent care, a poor or incomplete chart poses a significant problem for the dentist’s defense team. It can also diminish the dentist’s credibility if the patient chart fails to fully and accurately document essential and important items.
Documentation Problems
Errors and omissions in record keeping create patient safety and patient care issues that can result in significant adverse outcomes for patients. To address these documentation problems and improve care, we first need to identify what they are. (Recall that the first step in risk management is risk identification.)
Among the more common documentation problems we see in the charts of patients who have brought a claim are:
• Information that is missing from a chart that would normally be expected to be there. This includes a wide range of clinical information that is necessary for good clinical care, such as clinical exam findings, the results of the oral cancer screening, periodontal probings, diagnoses, treatment that was planned and/or performed, prescriptions, over-the-counter medication recommendations, and the patient’s informed consent. Sometimes we find that no chart entry was even made for a particular patient visit.
• The entry of a problem – swelling, infection, pathology, pain, etc. –without also having an entry of an action to address the problem. This is often a significant issue in oral infection cases that result in hospitalization and oral cancer cases that have severe or debilitating outcomes, including death.
• The chart contradicts itself. We see contradictions in tooth numbering, clinical findings, diagnoses, and treatment recommendations, to name just a few areas. Tooth numbering contradictions can lead to the treatment – including extraction – of the wrong tooth.
With these documentation problems in mind, let’s explore how to create records that avoid these pitfalls and reduce your risks.
Have a System
There are many advantages to implementing a system for creating and keeping records. In this context, a “system” is simply a process that is followed for every patient and patient visit, every time. Employing a system ensures that required information is consistently recorded and that your records are complete. Some characteristics of a record keeping system might include:
• The same forms – whether electronic or paper – are used for every patient
• The same information is recorded in the same place in every chart
• Responsibilities and expectations for recording information in the patient record are clearly defined for each member of the team – including dentists
• Information entered by an auxiliary is reviewed by the dentist, such as a hygiene exam note created by a dental hygienist or a progress note created by a dental assistant
You can apply a system whether you use electronic or paper charts. Most electronic dental record (EDR) systems have recommended protocols and training for creating, saving, and amending patient chart information, providing a structured system from the start.
Characteristics of Good Patient Records
Good patient records display a number of basic characteristics that, when looked at more closely, simply reflect common sense documentation.
They are accurate because the information in them describes what actually happened and is correctly recorded. They are complete, in that all pertinent and necessary information has been included. They are authentic because the information is reliable and has not been altered. And they are compliant due to their conformity with all state rules, requirements, and statutes.
One other characteristic of good clinical records is that they avoid general billing and fee information, except for when patients make clinical decisions based on fees. An example would be when a patient asks, “I can’t afford a crown. Is there anything you can do that’s less expensive?” In such a case, your progress note would include documentation that the patient declined the recommended treatment due to cost and inquired about other treatment options.
Elements of the Patient Record
There are many elements of a dental patient record, all of which are important for patient safety, good patient care, and sound risk management. Some elements will differ between practices based on the nature of the practice and the procedures that are performed, particularly for specialists.
Here is a sampling of record elements that a practice’s record keeping system (which we just discussed) should strive to include. In your own practice, you may have additional elements that are incorporated in your patients’ records.
• Patient personal information, including how the patient wishes to be addressed
• Medical history, including its review and all updates
• Dental history, including chief complaint
• Clinical assessment, including blood pressure, pulse, oral cancer screening, TMJ screening, periodontal screening, caries risk assessment
• Perio charting
• Diagnostic records, including radiographic images and CBCT, photos, and models
• Diagnoses, including your radiographic assessment and diagnoses
• Treatment recommendations and treatment plans
• Informed consent documentation
• Progress notes
• Prescriptions written and over-thecounter medications recommended
• Laboratory prescriptions/orders
• Referral communication
• Specialist and consultation requests and reports
• Patient correspondence, including pertinent phone calls, texts, and emails
• Acknowledgment of receipt of Notice of Privacy Practices/Health Insurance Portability and Accountability Act (HIPAA)
Now that we have a better understanding of what elements constitute the patient record, let’s move to the next point and examine how much information needs to be included in charts.
How Much Information Should be Written in the Chart?
PPP® claim professionals and defense attorneys have frequently heard dentists say, “Gee, I wish I had written more in my patient’s chart” when discussing the quality of the records after receipt of a claim. Our recommendation is to not wait for a claim – or even a patient complaint – to take steps to improve the completeness of your patient charts.
We stated earlier that the patient record’s primary purpose is to memorialize all the facts surrounding a patient’s care, and a second purpose is to be able to share patient information. We also said dentists aren’t expected to remember everything about every patient. Let’s take that premise one step further.
Instead of not remembering everything, suppose you couldn’t remember ANYTHING about ANY patient. Let’s say you have “total amnesia” about your patients. However, you still remember everything you have ever learned about how to practice dentistry. With that in mind, here is a simple test of how complete your patient records are – or should be:
Would you be able to read any one of your patient charts and quickly be able to know what treatment the patient has had and why, and perform whatever treatment is next for that patient and know why it’s necessary?
Now let’s take one more step with that same test and bring the “sharing” component into the question. Can your staff or any other
dentist read any one of your patient charts and understand those same things – based solely on what is written in the patient chart?
That level of documentation is important because “any other dentist” could be another dentist in your practice who is seeing your patient for an urgent situation. Or it could be a subsequent treating dentist elsewhere who is trying to make sense of what the patient has said about their prior care with you. It could be a dentist on the peer review committee or the state dental licensing board. Or perhaps it’s a dentist serving as an expert witness – for you or against you – for your malpractice claim.
It would be ideal to give all these dentists the most complete picture possible of all that transpired during your care of the patient, leaving no doubt that you treated the patient appropriately and within the standard of care. In short, complete and accurate records contain enough information to allow anyone who has no prior knowledge of the patient to fully learn about the patient’s care in your office.
Employing this record keeping standard helps practices from a business perspective as well, as patient records are frequently requested by third party dental benefit plans and their consultants or reviewers in order to adjudicate patient benefit claims.
What to Document in the Progress Note
Progress notes can be viewed as the narration of a patient’s care over time. They tell the patient’s story, more than any other part of the patient chart. To that end, it’s important for the progress notes to have all the details needed to understand what was done and why, and what comes next and why.
The length and content of a progress note can vary greatly depending on the clinical findings, conversations, and treatment involved. To make creating progress notes easier, electronic dental record (EDR) systems customarily have procedural chart note templates that pertain to specific types of dental care, such as evaluations, restorations, and extractions.
While the templates themselves are helpful, we encourage dentists to customize the template language to best suit their own record keeping preferences.
Here are some suggestions for what types of information to document in progress notes. Keep in mind that it’s important to write enough to pass the amnesia test presented in the last section.
• Medical history review and update
• Patient remarks, comments, and complaints – use quotation marks to quote them “in their own words”
• Clinical findings and observations and clinical diagnoses made
• Informed consent and informed refusal discussions and receipt
• All treatment performed (include details such as anesthetics administered and dosage given, tooth shade, file length, materials used, etc.)
• Complications during care and any corrective actions taken
• Postoperative instructions
• Prescriptions and medications
• Pertinent directives given to – and conversations with – patients, parents, guardians, and other providers
• Compliance and/or lack of compliance, such as canceled and missed appointments
• Referrals made and consultations requested
Documenting External Patient Communication
We have found that the communication with patients when they are not in the office is just as important to document as the communication that occurs within the walls of the practice, both from patient care and
risk management perspectives. These outside communications increasingly have been in the form of text messages and emails, rather than more traditional telephone conversations.
Whatever the mode of communication, it’s important to document pertinent exchanges in the patient record. Screen shots or photos of texts as well as email correspondence should be added, whether you have an electronic or paper format. Phone conversations will generally be documented in the form of a progress or general note. However, some electronic records have a specific screen and method of documenting phone calls.
External patient communications most often involve the scheduling, rescheduling, or cancelation of an appointment for care, postoperative questions and issues, medication questions and issues, and dental emergencies. These situations present a heightened risk for both the patient and the dentist, which is why their documentation is so important. The patient’s chart should always show that the dentist responded appropriately and in a timely manner in these circumstances.
If you are unable to reach a patient regarding a clinical issue, record it in the chart by simply stating something such as, “No answer, left message on voice mail” or “Patient did not respond to the text from the office.” Then, follow up with the patient later to ensure the patient’s clinical needs and questions have been addressed.
Putting It All Together
Accurate, thorough patient records that can pass the “amnesia test” go hand in hand with good clinical care. Good records preserve a dentist’s findings, communication, thoughts, and actions. They enhance patient safety as well. From a risk management perspective, they provide a front-line defense of any criticism of your care, whether it’s a simple complaint from a patient or something more serious.
The good news is that it’s easy to improve the quality of your record keeping. A few key steps are to use a system that provides consistency for you and your team, avoid the common errors and omissions, and take a few extra moments to be certain what you’ve recorded can be clearly understood by any subsequent reader – including you.
WELCOME BACK, DR. VASELANEY!
The PPP® is pleased to welcome Dr. John Vaselaney back to the program as the Director of Risk Management. Many of you are familiar with Dr. Vaselaney, as he previously served as the program’s director of risk management from 1995 to 2012.
Over those years, he presented over 300 dental risk management programs to dentists, dental students, and dental staff across the country, was the primary author of the program’s risk management newsletter and developed the PPP®’s first self-study and online risk management courses. If you were insured with the PPP® during that time, there is a good chance you attended a risk management seminar that Dr. Vaselaney presented.
Between his tenures with the PPP®, Dr. Vaselaney held the position of chief dental officer at a mid-sized dental support organization and also at a community health center. His activities in both roles focused on quality of care, risk management, and compliance and gave
him new insights into managing risk in settings and organizations beyond that of a traditional practice environment.
Dr. Vaselaney received his dental degree from the Case Western Reserve University School of Dental Medicine in Cleveland, Ohio and completed a two-year general practice residency at the Illinois Masonic Medical Center in Chicago. In addition to his clinical practice activities, he has also served as vice chairman and director of quality assurance for Illinois Masonic’s dental department and as administrative faculty in their GPR program.
Dr. Vaselaney is a member of the American Dental Association and the Academy of General Dentistry, and holds the designation of Associate in Risk Management (ARM) from the Insurance Institute of America.
We’re happy to add Dr. Vaselaney’s knowledge and experience to our team in support of our insured dentists and dental organizations.
For more information, contact The Professional Protector Plan® for Dentists @ 800-922-5694, or through the website: protectorplan.com.
