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
To be consistent, an office can choose to standardize charting notes according to the procedures performed and dental insurance coding. One way to standardize treatment notes is to following SOAP: Subjective – Objective – Assessment – Plan.12
In this manner, the subjective statements come from the patient. It can include their current symptoms and even encompass their current medical history. The team can use statements involving the patient’s description of their symptoms.
Objective statements will encompass the information gathered by team involving vital sign readings, oral and soft tissue exams, and the ordered radiographic images.
Assessment entries are the diagnoses made by the dentist as a result of the physical examination, subjective statements and objectives. It may include identified caries, abscesses, bone loss, or periodontal disease.
In the final plan notes, this can document the treatment administered at that visit, plus medications prescribed and any necessary referrals. These notes should address each procedure that requires a charge to the patient.
To standardize this process, these notes can be organized through a template. A template can save time as well as verifying that all notes are entered for risk management procedures. Using the SOAP method has also been helpful when completing dental insurance forms and the ability to refer to details is requested by the insurance company.
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 (Figure 4) and primary tooth letters A-T (Figure 5). 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.
However, orthodontic practices often use Palmer Notation System (Figures 6 & 7) . This system, also known as the Symbolic numbering system, involves each of the four quadrants and the numbering or letters begin at the midline. Each quadrant involves permanent tooth numbers 1 through 8 and must include a bracket to denote the quadrant. As with the Universal system, the primary teeth are noted with letters and utilize only A through E.
It is important to note which system is being utilized so that all patient documentation and possible referrals are consistent and/or converted for ongoing treatment.
Figure 4. Universal Numbering System – Adult.
Figure 5. Universal Numbering System – Child.
Figure 6. Symbolic (Palmer) Numbering System - Adult
Figure 7. Symbolic (Palmer) 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. Administration of sedation procedures, such as nitrous oxide and oxygen or pharmacological medicine to induce sedation, must also be documented. 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. An instance for this an include choosing a plain anesthetic over one that includes epinephrine due to recent heart attack, or uncontrolled diabetes or hyperthyroidism. More dental offices are performing soft tissue exams and vital sign readings at appointments. These should be included and documented offering a baseline history of findings. 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. 1As the saying goes, if it isn’t written down, it didn’t happen.
Table 1. Example of Patient Chart Entries
|03/15/20XX||7-MIF, Clearfil Shade A2. Ultra etch w/ Prime & Bond NT - prognosis good. N2O/O2 sedation, titration 3 of 8L (37.5%). Lidocaine 2% w/ epi-1:100K, 1 cartridge. No dental dam, Sectional matrix, no tx issues and dismissed after 5 min O2. POI regarding hardness, numbness, and flossing. Med history reviewed. Vitals = Resp 16, BP 132/88, Pulse 78, Temp 97.8. Questioned BP - has appt for re-ck. O2 rate did not dip below 95%||Jones DDS, Baker, CDA|
|04/21/20XX||19-MODL, Clearfil Shade A2. 1 Link Plus retention pin. Ultra etch w/ IntegraBond - prognosis questionable, large, if fractures will req. crown. N2O/O2 sedation, titration 2 of 7L (28.5%). Lidocaine 2% w/ epi-1:100K, 1 cartridge. Dental dam isolation, Sectional matrix, no tx issues and dismissed after 5 min O2. POI regarding prognosis, hardness, and numbness. Med history reviewed and HBP med dose changed to Losartan 50mg. Vitals = Resp 14, BP 120/78, Pulse 84, Temp 97.6. O2 rate did not dip below 95%||Miller DMD, Diller, CDA|
|04/23/20XX||Addendum to 4/21/20XX - 19-MOD Durafil Shade B1||Miller DMD, Diller, CDA|
|08/27/20XX||ex, bwx, pro, full soft tissue exam, perio charting - no significant findings, staining noted due to tobacco use. Discussed tobacco cessation, does not chew gum and rec nicotine lozenges as a start. POI regarding brushing technique and daily flossing. Rec return in 6 mos. Med history reviewed. Vitals = Resp 12, BP 122/84, Pulse 78, Temp 98.1||Jones DDS, Stuart 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