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Dental Records: Best Practices for Information Management and Retention

Course Number: 532

Risk Analysis and Management

Risk management is a process of identifying issues that could lead to malpractice or issue of noncompliance with state and/or federal regulations. Early detection and change of certain practices can lead to better record keeping and higher patient confidence.

Records that are incomplete do not justify the actions of the dental team and do not back the need for dental treatment.1 Treatment that is not listed in the record is assumed to have never happened at all and, therefore, assumed to have never been completed. Good patient rapport and communication can go a long way to establish the dentist-patient relationship, and this can further the confidence of the patient during any dental treatment.

Poor record keeping has been reported by legal professionals which led directly to the case being found in favor of the complaining patient. Records that are not completely legible or disorganized are laying the groundwork for the office to lose in a court of law.1

As stated, a lack of treatment planning and the lack of an updated medical history are found to be the top record keeping errors.8 As record keeping is often an area of issue, a dental office can perform randomized record audits to show the practice where they could adjust their current entry practices to reduce the chance for litigation. This can be done by randomly pulling physical dental charts or opening electronic records to verify consistency and legibility.

Practices that are using electronic systems to store and transmit patient information are required to complete security risk analysis under the Security Rule of HIPAA. Willfully ignoring this step has led to the uncovering of HIPAA violations that resulted in revocation of licenses, cancellation of contracts, severe fines and lawsuits.1,10 Tools exist if a dental office chooses to try this analysis on their own, but outside consulting or attendance of an educational seminar may be more thorough and offer documentation of the attempt of risk management. The analysis can identify possible charting omissions and/or threats to an inadequately encrypted system.