Detailed and well-organized records are a must-have for any modern dentistry practice. These are the legal records of your patient encounters and documenting them is important for your patient and your practice. Whether you’re anticipating an on-site quality assessment review or evaluating your own recordkeeping habits, following these tips can help you improve your records.
Every patient should have a file that describes their general medical history and specifics about their dental history. Any forms that patients fill out themselves should prioritize “yes” or “no” questions over open-ended questions. You should review your patient’s medical history with them to understand the full picture of their health and readiness for care.
Patient medical history should note:
Patient dental history should include:
For a more in-depth look at taking patient medical and dental histories, check out this article.
X-rays are a key component of a patient’s record of care. To be considered useful records, x-rays must:
Best practices for treatment plan records include:
Keeping a written key to abbreviations used in your office is important, not only for quality assurance examiners, but also for your office staff to review and quickly understand treatment notes.
To make your abbreviation key easily accessible, you might try:
Informed consent means that the patient has been educated and is knowledgeable of treatment options. Because every procedure presents its own set of unique circumstances, signatures with general statements like “I agree to allow treatment that is recommended by my dentist” do not meet the recordkeeping criteria for informed consent. Patients must be made aware of the unique risks, benefits, alternatives and costs for each procedure.
To meet the criteria for high-quality recordkeeping:
Outcomes of care are evaluated by reviewing patient records and are measured by current acceptable professional standards of quality. Although not common in dentistry, sometimes procedures don’t achieve the desired outcome. It’s important that you document all outcomes, including discussions you had with your patient about these outcomes. Included in this portion of the review are the successful completion and effectiveness of the following services, including documentation and follow-up:
This list highlights just a few aspects of a QA review and is a useful tool to help you review your practice through the eyes of the QA examiner.
For more information about Quality Assessments, please refer to the Quality Management section of the Delta Dental Dentist Handbook. Together with your staff, you can evaluate your office policies and procedures and be even better prepared for a future on-site QA review. For more posts about QA reviews, check out the quality assessment category.