Comprehensive records for orthodontic patients should include diagnosis, problem list, treatment objectives, treatment plan, treatment alternatives, normal and abnormal clinical findings, description of the treatment rendered, any referrals made, follow-up treatment, and recommendations, as well as documentation of all consultations, financial agreements, and insurance forms. The purposes of the patient’s clinical chart are to maintain continuity of care, register procedures performed in an ordered manner, remind the doctor of what was done and what needs to be done, and justify and support the medical necessity of the treatment provided to appropriate parties of interest. Appropriate documentation also includes communications between the orthodontist and other health professionals who are contributing to the patient’s care; thus, the dental record also protects the overall legal interest of all interested parties.
Quality orthodontic chart documentation can indicate quality care. Excellent documentation speaks volumes about the orthodontist’s competence and organization, which in turn increase credibility. Laypeople are not expected to document treatment, but an orthodontist is expected to keep permanent records of what acts and activities transpired during doctor-patient encounters. In addition to documenting the diagnosis, treatment plan, mechanotherapy, archwires, and elastometrics, there are several strategies on what else to document and what not to. The following strategies are presented to help the orthodontic community more accurately reflect the patient’s orthodontic care, whether this documentation is in paper or electronic format. These guidelines should be modified as needed for each practitioner and patient.
Document facts, findings, treatment, and incidences objectively. Objectively documenting both positive and negative clinical findings is essential and supports the notion that the orthodontist constructed a comprehensive diagnosis and treatment plan before providing orthodontic care. Orthodontic therapy can, on occasion, result in a poor outcome, a dissatisfied patient, or unexpected complications (eg, root resorption, excessive tooth pain or mobility, enamel destruction, periodontal deterioration). Documenting relevant facts without obscurity, humor, sarcasm, or personal comments goes a long way toward supporting one’s actions relating to any difficult situations subsequently encountered. Throughout documentation, it is essential to avoid derogatory or disparaging comments about any patient, parent, colleague, or anyone else involved with the patient’s care.
Document the patient’s chief complaint, diagnosis, signs, symptoms, and all existing conditions. The patient’s chief complaint, diagnosis, all clinical findings from a comprehensive oral examination, as well as interpretations from photographs and radiographs should all be documented. Document existing or deteriorating conditions such as TMD signs or symptoms, gingival conditions, evidence of bruxism, and other findings perceived by the doctor or reported by the patient. The patient should be apprised of these findings to negate the perception that they were caused by the treatment rendered.
Document the pros and cons of all treatment options, including no treatment and the patient’s choice. The treatment plan should address each item noted in the problem list. It is essential to document that the patient or the parent was informed of the ideal treatment plan, all alternative treatment options, a no-treatment option, any probable complications or limitations associated with each proposed treatment plan, and the patient’s final choice. This establishes evidence of providing patient-centered care. Patients should always be informed that if the clinical presentation changes in any substantive manner, the treatment plan or the planned outcome may need to be revised during treatment. Any treatment plan alteration during treatment requires documentation of the reason or justification for the change.
Document obtaining patient informed consent. In addition to having the patient sign standard informed consent forms, fully disclose and document any specific risks associated with the treatment. The esthetic and functional benefits of orthodontics are more known among laypeople than the risks and limitations. If the proposed treatment is elective, it is even more imperative to disclose and document all probable risks and limitations. Note in the chart that these risks were explained in simple layman’s terms. A treatment with a high potential for risks, limitations, or relapse needs to be carried out with caution, and only when the patient voluntarily consents based in a well-informed decision. This documentation proves that a 2-way exchange of information took place. Document that the patient understood and accepted the treatment and was given time to ask questions, and that all questions were thoroughly answered. In all cases, remind each patient that achieving an ideal smile and bite cannot be promised, but improvements can be made. It is prudent to make a note in the chart that the patient’s consent was obtained in both written and verbal forms.
Document informed refusal. Refusing or delaying recommended treatment should also be documented. Rejecting a proposed treatment or choosing an alternative option over an ideal recommended treatment because of cost or any other reason requires documentation. In addition, a patient’s refusal of a recommended medical or a dental procedure, along with the probable consequences of that decision, requires documentation. Examples include refusing to allow radiographs to be taken, to consult with a periodontist about periodontal conditions before orthodontic therapy, to extract teeth, or to comply with any medical advice or referrals.
When the patient chooses specific appliances or a treatment course, disclose and document the limitations. Patients, especially adults, may request a specific treatment such as ceramic brackets, lingual braces, or clear aligners. The improvements in these treatment modalities have been remarkable. However, if there are specific limitations or risks suspected with any of these methods, the patient must always be informed. If a patient requests a specific treatment in contradiction with the orthodontist’s recommendation, the orthodontist has 2 choices. The first is to acquiesce. This obviously cannot be done if the treatment will result in harming the patient. The patient cannot consent to or allow the doctor to perform negligent treatment. The second alternative is for the doctor to refuse to treat the patient, citing practitioner autonomy as the basis for that decision. All of this requires accurate and careful documentation.
Record all entries accurately and in a timely manner. The patient’s chart is a legally recognized document of every encounter between the patient and the doctor, including treatment provided to family or staff on a pro bono basis. Failure to document every encounter could lead to questions about other relevant omissions. The veracity of the entries in a patient’s record should never be in question. Entries should be timely, comprehensive, accurate, clear, and trustworthy. Avoid excessive or ambiguous abbreviations, especially if not commonly used. Notes should be written so that others can understand them, especially orthodontists. Entries into the chart should be made contemporaneously when the services or consultations were rendered. Late or erroneous entries should be clearly identified as such, including the correct time and description of services rendered. It is better to add an amendment to an entry rather than to delete or change an entry. Alterations to the patient’s paper or electronic chart made after the fact to hide mistakes or add facts are fraudulent and carry significant consequences both civilly and administratively.
Document the thought process and the reason or rationale for taking actions. Careful assessment and documentation of actions undertaken, including extenuating circumstances and any rationale behind them, are important. The addition of a few words about the thought process can improve documentation and justify the actions, especially in complex and interdisciplinary cases. Short statements usually suffice. Examples might include the following: the severe dentoalveolar protrusion requires premolar extraction; the continued worsening of the oral hygiene with no treatment progress justifies treatment termination; and so on.
Document treatment progress and next-visit observations. It is valuable in complex cases, or in those requiring significant tooth movement, to document how the case is progressing, especially if photographs are not taken. For example, document occlusal relationship improvement, reductions in spaces and overjet, resolving of crowding, and so on. Doing so makes the overall treatment notes flow well. Sharing the recognition of treatment progress with the patient or parent is a good method of relationship building. In addition, document next-visit observations to be made, such as observing oral hygiene improvement after giving oral hygiene instructions.
Document that excellent care was rendered. It is possible to convey that excellent care was performed. For example, it can be added to the bonding or debonding notes that the patient tolerated all procedures well. Before initial bonding, document in the chart that the medical and dental histories were reviewed. Consider taking vital signs before this appointment if the patient is medically compromised. If a patient is dissatisfied with treatment, document that the office was responsive, and the patient was reassured that his expectations will continue to be addressed. Alternatively, if the patient is pleased with the outcome of the treatment, document that response before appliance removal.
Document all important instructions or recommendations given to the patient. When giving any advice, warning, or recommendation, document that this information was given. Make a note in the chart if you give a patient an educational brochure or handout, or showed an audiovisual educational tool. Document recommended interceptive treatment, extractions of deciduous teeth, diagnostic tests, medications, prescription toothpastes, and specific hygiene instructions. Specific professional advice could be recorded via simple statements such as, “Detailed hygiene instructions and consequences of poor hygiene were explained to patient and parent.” Repeated advice should be documented every time.
Document when the patient does not cooperate or follow instructions. The orthodontic patient is expected to act reasonably and follow instructions before, during, and after treatment. If a patient does not follow instructions (or even worse, engages in self-destructive behaviors), it is important to record contributory negligent acts in the chart. Poor oral hygiene or elastic wear, breakage of appliances, excessive numbers of missed or cancelled appointments, and unsuccessful efforts to reach disappearing patients need to be recorded. If poor oral hygiene is noted, document the degree or severity of plaque accumulation, white spot lesions, and gingival conditions. Photographic documentation is extremely helpful. Recording instances of poor cooperation as well as all discussions with the patient or the parent are essential. This is especially true if the child develops negative side effects or if the orthodontist decides to terminate treatment later when continued treatment would result in more harm than benefit.
Take photographs when the patient does not cooperate or follow instructions. As noted above, in addition to the documentation of poor cooperation in the patient’s chart, taking intraoral photographs throughout treatment is an invaluable tool. The objectives can be to hold the patient responsible for his own noncompliance, to help motivate him to do better, or just to visually document the progress of all treatment rendered. For a child with poor oral hygiene, taking an intraoral photograph and zooming in on it on a large computer screen can often cover all 3 objectives. Lack of treatment progress justifies taking photographs as well. For example, a patient not wearing interarch elastics and not progressing can be documented through a series of photographs at multiple points along the treatment timeline and can ultimately justify a decision to terminate treatment.
Whenever early treatment termination is eminent, document relevant discussions, correspondence, and reasons for termination. Extensive documentation is required if early treatment termination is imminent. Document each occurrence of noncompliance and all discussions, including the one in which you give the ultimatum of treatment termination if noncompliance continues. If it is a noncompliant child, document all discussions with the parent or guardian. It can also be helpful to notify the patient’s primary care provider with the intent of first informing him or her of the patient’s status, to attempt to enlist his or her support in trying to correct poor behavior or cooperation, and to allow for additional monitoring and timely interventional treatment to be performed if required. It goes without saying that if you decide to discontinue active treatment or terminate the doctor-patient relationship, a detailed written notice of your decision should be mailed to the patient that includes notification that the patient requires appliance removal, that you will be available on an emergency basis for a reasonable period of time, and that he should seek substituted care with another practitioner if he wishes to continue with the treatment.
Notify the patient of negative or unexpected outcomes and document the disclosure. A bad or even lesser outcome does not equate to malpractice. If it is expected from a proposed or requested treatment, such as limited treatment, it should be disclosed before the initiation of treatment. If it occurs during comprehensive treatment, documentation of the discourse to either continue or terminate treatment should be made. A poor outcome may not be a problem, but failure to inform the patient is. In addition to all discussions with the patient, obtain records, including intraoral and extraoral photographs, as well as radiographs if needed. If radiographs show any negative sequellae to the periodontium or dentition, disclose and document these findings along with their clinical significance to both the patient and the patient’s general dentist.
Document completion of active treatment. It is essential to document when active treatment is completed. It is a good practice to inform the patient that treatment is completed on the day of debonding, notwithstanding that retainer checks will be made afterward. Many patients do not show up for appointments during retention. Welcome patients for follow-ups in the long term if needed. Mailing a treatment completion notice to patients could be beneficial, including advising of regular cleaning and checkups with the patient’s dentist. Be sure to inform the patient of his retention protocol and tell him to immediately call the office if retainers are lost or deformed so that they can be replaced or repaired.
Conduct a posttreatment consultation and document the discussions. Posttreatment consultations comparing initial and final records are valuable for improved doctor-patient relationships, resolving ill feelings, creating future referrals, and starting the running of the statute of limitations. Inform patients what was achieved, such as improved dental alignment, bite, and vertical and horizontal dental relationships. In addition, inform the patient what was not achieved or things that were compromised, such as the inability to achieve an ideal bite. You do not want a colleague to tell the patient these limitations. Disclose and document findings of decalcification, external root resorption, and periodontal breakdown, as well as reassurance for the patient and any possible clinical implications. It is often better to refer the patient to his general dentist or to an oral and maxillofacial surgeon for consultation regarding the status of the third molars than to make specific recommendations for extraction.
Document all referrals to other health care providers. Interdisciplinary care needs to be carried out effectively. Referrals require appropriate documentation, including keeping a hard or digital copy of the referral form in the patient’s chart, as well as appropriate follow-ups. Be sure to document the reason for referral and to whom the referral was made. A copy of every referral for consultation, extraction, or any other service should be kept in the patient’s chart, whether in paper or digital form. Whenever a patient declines a recommended referral, document this event and any probable negative consequences relating to this decision.
Document abusive or inappropriate patient behavior. Inappropriate behavior or attitude, demeaning or threatening language or actions, sexual advances, or serious patient disgruntlement should be documented. These notes should be kept in a separate file specific to that patient and dated by occurrence for incorporation by reference if needed. When a clearly flirtatious patient is encountered, ensure that another staff member is present and document anything that constitutes inappropriate behavior or language. Staff members should also document inappropriate behaviors whether made in person or over the phone. If a patient voices a complaint or makes inappropriate comments, document his exact words using quotation marks. Indicate which staff member was present when the incident occurred. Discuss with the patient your expectations that he should ameliorate the behavior and document the patient’s acceptance or rejection of these expectations. If the patient apologizes, be sure to note it in the record. If the misbehavior continues, it is advisable to terminate the patient’s treatment.
Maintain all documents and records securely and as long as reasonably practicable. Each state has different rules regarding the number of years that patients’ charts and records should be kept. These rules often differ between adults and minors. To be safe, in our digital era of ever-improved capabilities of secure and HIPAA-compliant data storage, it is prudent to keep all patient documentation and records indefinitely, especially for potentially litigious patients. This is especially true in orthodontics because patients experience relapse or loss of their retainers and occasionally return for retreatment.
The general presumption for documentation is that if it is not in the chart, it did not happen, and vice versa. Therefore, it is essential that documentation be both comprehensive and accurate. Effective documentation tells the orthodontist everything he or she needs to know about the patient’s diagnosis and treatment. It can defend a claim of malpractice years after treatment and should not be biased, altered, or subjective.
There are 2 occasions when a patient’s exact words or comments should not be paraphrased and must be documented in quotation marks. These include the patient’s chief complaint and inappropriate comments or complaints from a patient. Specific patient requests and accommodations (both acceded to and denied), questions, disgruntlement, or lack of cooperation should all be thoroughly documented. It is also beneficial to document simple positive statements such as the treatment plan was reviewed and accepted by the patient, or the patient is happy and satisfied about treatment progress or the result.
Documentation should be complete, legible, clear, unaltered, objective, and accurate. Poor recordkeeping is indefensible, and excellent documentation is expected in health care. Excellent documentation shows that the practitioner is competent and professional. Documentation should not be made merely as a defensive practice. If viewed as a sword rather than a shield, it provides a great communication tool, increases the quality of patient care, and fosters a strong doctor-patient relationship.