Patient dental records are legal documents. They are a factual representation of the patient’s dental treatments, diagnostics, correspondence, and consultations. They must be accurate, meaningful, and factual. If they are handwritten, they must be legible, otherwise they are meaningless. The patient’s treatment records should contain information that would allow another dentist or an expert witness, if needed, to understand the treatment provided and the manner in which it was performed. It should also contain any pertinent information relative to the treatment being provided. Many offices have gone paperless in the last decade, with more to follow in the future. However, there are still some offices that still use paper records for a variety of reasons. Expert witnesses must rely on the legibility and retrievability of the record to be helpful in the case of an alleged malpractice lawsuit. The 14th of almost 30 record-keeping errors in the American Dental Association (ADA) survey mentioned below was “records not legible.”
A survey done by the ADA in 2005 that covered the time between 1999 and 2003 found, from the 15 dental malpractice insurance companies surveyed, that the top six record-keeping errors were:
1. Treatment plan is not recorded.
2. Health history is not clearly documented or upgraded regularly.
3. Informed consent is not documented.
4. Informed refusal is not documented.
5. Assessment of patient is incompletely documented.
6. Words, symbols, or abbreviations are ambiguous .
It is permissible to use abbreviations that are commonly used in dentistry. To use your own personal shorthand abbreviations within the paper or computerized chart, which would be hard for another dentist or expert witness to decipher or have no meaning at all, would be an injustice to you and your patient. Making entries into a paper chart should be in black ink since it copies the best. Pencil is not allowed, nor is highlighter. Also be sure to enter any “no show,” “canceled,” or “came late” appointments to indicate the patient’s noncooperation and to record the patient’s failure to have adequate home care or failure to follow referrals as noted in an informed refusal. This will help show comparative or contributory negligence. If a mistake is made in the record, do not white out, scratch out, or try to transfigure it. Simply draw a single line through the wrong entry and continue with the proper one. In many of the dental practice management software programs available, changes may be made up until a certain “lockout” time limit occurs. Most software “lockouts” occur automatically at the end of each month. It is very important to have this feature, because without an automatic “lockout,” the records are open to possible falsification, which would make the records untrustworthy and indefensible in a malpractice lawsuit. If an error is discovered after the “lockout” period, make a corrected entry as soon as possible with the notation that it is a correction to a previous entry. Note it as a “late entry” (for more on this, see Chapter 14). At the end of each entry, always have the person who is making the entry, including any auxiliary personnel, initial that entry. Do not leave lines blank or pages unfilled. If this occurs, draw a line through the blank area to signify that nothing was added to that entry after the entered date. They should not contain any subjective statements or opinions regarding the patient or the treatment. Any correspondence with a malpractice attorney or your malpractice insurance company is to be kept separate from the patient’s dental records.
The purposes of good dental records include:
1. Recording the health status of the patient at the time of the initial examination
2. Recording the treatment provided to the patient
3. Providing legal documentation on behalf of the patient, the courts, third-party payers, or the patient’s heirs
4. Providing legal documentation in the defense of legal claims made against the dentist
5. Fulfilling the laws regulating professional services
6. Advancing medical research
7. Contributing to quality assessment and assurance
8. Providing communication among health practitioners
9. Helping identify victims of a mass disaster .
Records should include the following information: