Clinical Components of the Dental Record
Each office must decide which office documents are necessities to running a dental business and providing quality dental care. Finkbeiner and Finkbeiner (2020) divide documents into categories of vital, important, useful, and nonessential.
Vital records are irreplaceable documents. These are clinical notes, financial records, and the legal documents regarding the business. Important documents are valuable to the practice tracking accounts payables and receivables, including payroll. These records are best retained for 5-7 years, but dictated according to the federal and state’s regulations. Useful records are more difficult to define as different offices use certain documents differently and therefore place differently value accordingly. These documents may include employment applications and older banking information. These documents must be cleared before disposal. Nonessential records may include outdated notes and vendor pamphlets.6
Some offices strive to be paperless (completely electronic) while other practices are required by state law, such as in Minnesota.7 For those offices still generating paper documentation, a file folder must be created for filing and saving. The file folder will have the patient name and/or number in view, as well as an aging label to show the last year of treatment.
A majority of offices are going with electronic formats or combination formats where some notes are paper and some are electronic. Some offices with original paper documents will scan them into the patient’s record and save them in an electronic format. This type of practice is referred to as a chartless practice. Several of the documents referred to in the course are often started in paper format by the patient. After the patient completes the form, a business assistant will transfer that information to an electronic format via data processing or by scanning and saving the document electronically.
As the clinical record is considered vital, documents that substantiate treatment and the standard of care are very important. Before treatment, patients must be informed of the practice privacy notices and acknowledgement must be received. The office may choose to complete a dental history to offer a baseline of treatment and gauge patient compliance. Patient treatment requires an updated medical history, clinical chart with treatment record and progress notes, periodontal screenings, and radiographic images. To complete monetary transactions, a patient registration form which includes financial responsibility and/or insurance eligibility must be obtained. Additional forms that an office may choose to maintain include treatment consent forms, lab requests, referral forms, and the signature-on-file form. Should any of these forms be on paper, a file folder must be used to contain each patient’s information.
Privacy Practice Notice
Each practice must have a document prepared that describes how their protected health information (PHI) will be used by the office for treatment, payment, and healthcare operations. This notice will also state how the patient’s information will be secured and protected. The notice is followed up with a signature, asking the patient, parent, or guardian to acknowledge that they received the policy.
The registration form contains specific information regarding patient identification and demographics. A patient’s social security number will not be requested due to privacy issues unless the office can show proof that it must use this number versus an alternative specific identification generated by the practice. If the office does prove need, the practice must have the ability to block or encrypt this information from intruders or computer hackers. The form will often ask for the patient’s full name, mailing address, work or student information, and electronic contacts. Phone numbers for home and work will be received as well as cell phone information and if they choose to receive electronic texts or alerts. This form will show if the patient or parent will be billed directly in full or if they have dental insurance. If insurance (primary and secondary) will be billed, information regarding the name, address, and group numbers will be found here. This form may also have a line that requires a signature to prove that the Privacy Notice was offered/received.
If the patient is covered by insurance, the office will often obtain a Signature on File form. When the patient, or parent/guardian signs for this, it authorizes billing to insurance without having the patient sign every time. If this signature is collected electronically, it can be attached to documents before forwarding. To caution, this signature is only to be used as the patient has designated for insurance purposes.
An updated and thorough medical history is a vital document and necessary for providing the standard of care due to the patient. This continuously changing and updated document serves as a prompt for the team to discuss and verify answers provided by the patient or guardian. Additional notes should be recorded regarding new prescriptions and medical conditions that are explained by the patient in more detail.
As the goal for patient treatment revolves around providing total care, the office must have an updated medical history at every dental visit. This is often overlooked, and even more often if the patient was recently treated. An important fact to remember is that a health history can change with an event as minor as a prescription change. If this change is not asked for and noted, the patient may have an adverse reaction during treatment. The office should develop a policy regarding the length of time between reviews versus completing a new form.8
Additional focus has been given to prescriptions involving opioids for pain management. Informed consent involves alerting the patient to the benefits, side effects, possible dependency, and overall risk in taking these medications. An office may choose to have the patient sign an additional document verifying they have been apprised of their script options.1
Figure 8. Medical/Dental Questionnaire
When the patient is seated for treatment, vital signs may be obtained and added to the history. Obtaining the patient’s respiration rate has become more common since the Covid-19 pandemic. This rate must be obtained if the patient will receive a conscious sedation technique such as N2O/O2 sedation. Taking the patient’s blood pressure and pulse rate with an automated unit along with their temperature are added to the patient record. This provides an opportunity to discuss the patient’s overall health before dental treatment begins. The dentist is ultimately responsible for ensuring an updated history. According to an article published in the July, 2015 CDA Journal, “an unclear or out-of-date health history is the No. 2 record-keeping error in dental malpractice proceedings based upon a survey by the ADA of 14 professional liability carriers.”8
The medical history is completed by the patient. If the patient is a minor, the form should be completed by the parent or legal guardian. In either case, the form can be on paper, or can be completed in electronic format. If on paper, the form(s) can be mailed prior to the appointment. By mailing or electronically mailing the forms, the patient can complete them in pen at home as they have time and have access to physician names, phone numbers, and easy access to medicine labels. When confirming appointments, it is best to repeat the need to bring these completed forms. Some offices will start the process with the patient on paper and then scan the document into the record to eliminate the need for storing paper documents.
Some offices are posting these physical forms to their office website, the patient can enter the information electronically to an encrypted site and then save it to a special folder so it can be sent securely to their own record. In this case, a review of the form in person is necessary to be sure all was properly understood and transferred correctly.
If forms are to be completed at the time of treatment, the patient should be asked to arrive early to allot enough time to complete them. Offering a clipboard and pen give them something to write on and offers privacy to the reverse side of the forms. In all cases, the patient must be assured that these forms are confidential and their privacy will be maintained.
With patient diversity increasing, it may be necessary to provide office forms in different languages. The Dentist’s Insurance Company of California (TDIC) shows many examples of consent forms.
Clinical Treatment Records
Several forms and diagnostic records will be generated during a patient’s treatment. The clinical chart tracks what happens with every patient encounter. The office may choose to complete an initial exam form that shows previous dental treatment. This may document current findings such as oral hygiene and a TMJ evaluation. Once completed, this form is kept and not altered.
Informed Consent forms are obtained before restorative treatment. These forms show that the patient understood the recommended options for treatment, had the opportunity to ask questions, and consented to their choice of treatment. In contrast, Informed Refusal forms must be obtained when the patient does not consent to receive recommended treatment. After a period of time and continued refusal, this form can be a basis to show contributory negligence and release the patient from the practice.
Progress notes will be entered at each patient encounter whether it be via office or teledentistry appointment, phone call or professional consultation. This document details patient complaints, treatment provided, work completed, and the anesthetic and dental materials used. Additional information to record will be missed appointments, home care instructions, treatment prognoses, and prescriptions. Should the office choose to accept the patient’s implied consent (consent relying on patient actions), this should be noted in the progress notes.
Furthermore, the team may complete a treatment plan to detail what procedures should be completed and/or state when the patient is to return for prophylaxis. This form may offer a priority list according to the findings in previous treatment. These can all be in paper or electronic formats. If electronic, the information is often entered directly into the chart at chairside to save time and maintain accuracy. Based upon a survey of professional liability carriers, undocumented treatment plans top the frequency of record keeping errors.4
Diagnostic images such as intra- and extra-oral radiographs and photographs will be kept in the file or stored electronically. The periodontal screening process will occur as prescribed by the dentist and saved to show areas of progress and progression. Diagnostic models are used in patient treatment but cannot fit into the actual record. These casts are often boxed and stored in a closet with the patient name or cross-referenced number.
Additional forms that dental offices often utilize are a combination of the following forms. Some of these can be combined together previously mentioned, where these forms may stand alone.
Recall/Recare exam form – updates care received and noted during prophylaxis visits.
Medication history – a form that logs all current medications plus those prescribed during treatment.
Correspondence log form – logs all calls from the patient, specialists, laboratories, insurance companies, etc.
Financial arrangements – works with the consent form to verify how the treatment fees will be paid.
With the incorporation of a true EDR, communication between the patient and the dental team should improve. If all of these forms were incorporated, the dental software program could generate charts, images, and instructions to aid the dental team in offering home care instructions.9