Making Entries in the Patient Records
Whether the entry into the dental record is handwritten or electronic, it must be complete and consistent with all other patient record entries. Additionally, each time the record is accessed during treatment, the aseptic chain must be maintained to prevent cross contamination. Personal protective equipment (PPE) is not required in the business areas of the practice so protective barriers must be utilized on equipment such as keyboards and portable room tablets.
If handwritten, the information must be complete, legible, and entered in non-erasable ink. As this is a legal document, treatment procedures and the names of dental materials must be spelled correctly. If the entry is electronic, the software has a program that tracks all entries by identifying the person who accessed the record. The entry is saved after a period of time and, if an alteration is made, the responsible person and entry is also tracked. This is another reason why a pass code or phrase must never be shared. While handwriting is not an issue with electronic records, correct spelling is still necessary.
In both cases, entries must be accurate and factual. Even as the patient is describing the reason for their visit, descriptions, or symptoms, the statements must be documented as said without inference. Statements must be truthful and objective (as opposed to subjective and inferring opinion) except for those related by the treating dentist regarding possible diagnosis, treatment plan, and prognosis. Signs are what is seen (ex. abscess, swelling, widened periodontal ligament space in a radiograph) and collected while observing the patient. Facts include date of treatment, updated medical issues, and the tooth/teeth with their involved surfaces under treatment.1
Treatment is often abbreviated and must be standardized to eliminate any error. Offices often maintain a copy of abbreviations and symbols in case any are questioned. It is especially important to remember standard abbreviations versus those used in common texting. Incorrect acronyms can accidentally be entered out of habit and compromise the integrity of record keeping.5
Most offices often commit to using the Universal numbering system involving permanent tooth numbers 1-32 and primary tooth letters A-T. This numbering system always begins at the patient’s upper right side and moves across to the upper left side, down to the lower left side and finishes at the patient’s lower right quadrant.
Figure 4. Universal Numbering System – Adult.
Figure 5. Universal Numbering System – Child.
Tooth surfaces are abbreviated as follows:
M – mesial
D – distal
O – occlusal
I – incisal
L – lingual
B – buccal (for posterior teeth)
F – facial (for anterior teeth)
Examples of common treatment abbreviations as follows:
BA – broken appointment
BOP – bleeding on probing
BW, BWX – bitewing radiographs
CRN – crown
Ex – exam
EXT – extraction
Flu – fluoride
NKDA – no known drug allergies
NSF – no significant findings
PA, PAX – periapical radiograph
P.O. – post operative
Pro, Prophy – prophylaxis
Tx – treatment
WNL – within normal limits
Anytime that anesthetic is administered during treatment, the name, epinephrine ratio, and number of cartridges must be noted. An additional notation on how the patient tolerated the anesthetic and procedure overall is good follow up. If a certain anesthetic is chosen specifically due to a medical condition, that is also noted. More dental offices are performing soft tissue exams and vital sign readings at appointments. These should be included and documented offering history of findings. As periodontal screenings are performed, these findings must be included in the record. As a periodontal condition is often the reason for litigation, the office must work to protect itself and discuss these matters with the patient and record any treatment plans and patient referrals.3
Any dental materials used during the procedure must be noted by name. Examples may include type of amalgam, composite, primer, bond, number and type of radiographic images, and alginate. In a specialty procedure such as an extraction requiring sutures, the kind and number of sutures placed must be noted along with any removal complications such as root/crown-dissection.
Home care instructions and information on follow up appointments must be recorded. Recall/recare appointments regarding recommended time frames to return must also be noted. Should the patient not reappointment or follow home care instructions, this also must be documented to show possible patterns of noncompliance and contributory negligence.
Additional notes into the patient record may include telephone conversations on a correspondence log, referrals to specialty dental offices, and medications prescribed before or after treatment. Knowing this information, entries must be comprehensive. The idea of fitting the procedure into a certain amount of spaces or lines could directly relate to inaccuracy and incomplete notes. It is better to be complete as notes omitted are assumed in a court of law to have never existed.1
|07/19/20XX||4-MO, Clearfil Shade A 3.5, Ultra-etch, Prime and Bond NT, 1 cart. Lidocaine 2% with epi 1:100K, sectional matrix, dental dam, no tx issues. Med hist. was reviewed. Vital signs: BP-128/84, Temp-98.4, Pulse 82. P.O. given regarding hardness and numbness.||Jay, DDS/AB, CDA|
|08/12/20XX||19-MOD, Clearfil Shade A 3.5, Ultra-etch, Prime and Bond NT, 2 cart. Lidocaine 2% with epi 1:100K, sectional matrix, dental dam, no tx issues. Med hist. was reviewed. Vital signs: BP-128/84, Temp-98.4, Pulse 82. P.O. given regarding hardness and numbness.||Jay, DDS/AB, CDA|
|08/14/20XX||Addendum to entry 08/12/20XX|
#19-MOD, Durafil Shade B1
|Jay, DDS/AB, CDA|
|09/08/20XX||Ex, BWX, Pro, full soft tissue exam – NSF, staining noted and due to tobacco use. Med hist. was reviewed. Vital signs: BP-122/76, Temp-98.6, Pulse 74. Discussed tobacco cessation, does not chew gum, recommended nicotine lozenges. Will return in 6 mos.||Jay, DDS/ SR, RDH|
Once an entry is made, the office must commit to a standard number of spaces between entries. If one or two lines of separation are always used, this will be expected throughout the records. If this space is not there among entries, it could be seen as an alteration to the record and may be scrutinized for validity. Certain steps are to be followed if an entry is found to be incorrect and require an addendum. First, it is important not to obliterate the entry. Place one line through the incorrect entry. At the next possible space, correct the entry, referring to the date. Do not ever use correction fluid on the incorrect entry. Doing so gives the impression to the reader that the office has something to hide.
If a record is under suspect with a court, expert document examiners may be subpoenaed to study the entries. These professionals can determine if an entry was altered (made at a later date, same author, same pen, and ink.) Experts look at factors such as the dryness of the ink (which identifies entries that were made at different times) and the penmanship of the writer which includes looking at pen pressure, speed, slant, and differences in writing surfaces.2