Dental recordkeeping is a time-consuming task, and it is crucial for all dental practitioners to acknowledge that maintaining comprehensive and meticulous records is never excessive or unnecessary in any scenario. Even the most basic data collected during a dental exam is critical to the outcome of a patient’s testing and treatment. Plus, all records – including Electronic Health Records (EHR) are important if the patient ever makes a claim of dental negligence or malpractice.
Today, electronic records have eased the management and maintenance of records and relevant data. It has added a good level of convenience for the filing and storing of sensitive data. Such digital capability enables dental practices to maintain files and images with ease and ensures accuracy and confidentiality.
What’s Included in Most Patient Dental Records?
The dental record of a patient serves as a dynamic file documenting a lifelong oral health care history. Dental professionals need to update a patient’s medical record during each episode of care. The patient’s dental records must include –
The Need for Regular Audits
Conducting routine audits of patient records is an effective measure to mitigate any incidences of miscommunication or confusion. Maintaining proper dental recordkeeping entails the entry of precise information into patient records, coupled with periodic verification to minimize potential complications as to when and when a case could arise.
If there are any intended modifications to be made in the recordkeeping process, it is advisable to discuss the same with the concerned team. One would also need to furnish comprehensive documentation of the modifications made as this enables all team members to refer to the revised structure at a later date.
Strict Confidentiality is a Mandate
Privacy is a highly regarded value among individuals, as a rule. This holds especially true when it concerns the overall healthcare industry including dentistry.
If physical copies of patient records need to be transported, it is important to ensure that a protective cover sheet is utilized to safeguard the privacy and confidentiality of the medical history.
It is imperative that the dental team exercises caution while accessing patient information in shared spaces.
By switching to digital platforms and deploying an EHR or Electronic Health Records system, the practice can effectively mitigate the inherent risks that accompany conventional paper-based charting processes.
A seemingly inconsequential aspect of a patient’s record has the potential to swiftly escalate into a predicament. Maintain the integrity of data input by refraining from deleting, altering, or leaving blank spaces intending to complete them later. Engaging in such petty actions may give rise to perceptions that one has engaged in inappropriate manipulation of records.
For conventional paper-based record-keeping procedures, one must strike out errors with a single line, subsequently adding the date and initials to authenticate the correction.
Treatment Refusals Need Documentation
Even with sound treatment recommendations, patients may not always concur. When encountering patients who do not always comply, it is imperative to document this information accurately in their records. Record detailed minutes during conversations pertaining to the advantages and disadvantages of treatment options, while specifying the rationale behind a patient’s decision to decline the recommended course of action.
Well-kept Records are Always an Ally
Apart from ensuring optimal patient care, the dental record holds significant value as it can serve as valuable evidence in legal or regulatory contexts, precisely establishing the diagnostic analysis as well as the treatment administered to the patient. An accurately maintained dental record serves as a valuable resource to address patient concerns, defend against claims of malpractice, or substantiate treatment rendered, particularly during external audits by third-party payers.
In each of these instances, the data retrieved from the record will aid in justifying the diagnosis and treatment rendered, as well as adherence to applicable benchmarks for quality healthcare.
In cases where the patient’s medical records are incomplete or inadequate, the dental practice could be blamed for failing to meet its obligations in maintaining accurate and thorough documentation.