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Partnering with you to help create healthy smiles

Keep your records in shape: Do’s and don’ts for recordkeeping

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. 

Medical and dental history

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:

  • Regularly used prescription and over-the-counter medications
  • Diagnosed physical and mental conditions
  • Familial medical history
  • Past surgeries
  • Allergies

Patient dental history should include:

  • Baseline charting of existing oral conditions and missing teeth
  • Patient’s initial complaint or reason for seeking care at each visit
  • Pathology, including caries, defective restorations, fractured teeth, endodontic involvement, condition of dentures, etc.
  • Observations regarding pocket depth, inflammation, recession, oral hygiene, etc.
  • Potential oral surgery needs and any impacted teeth

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:

  • Be labeled with the patient’s name and the date of the x-ray
  • Be taken by properly trained and licensed staff
  • Be diagnostic quality
  • Be easily accessible
  • Be taken at standard professional rates, depending on patient’s age and caries index

Treatment plans

Best practices for treatment plan records include:

  • Writing them in ink, saving them digitally or printing them
  • Keeping the records even when treatment has been completed, though checking off items or steps is acceptable
  • Signing your treatment notes, even if you’re the only dentist at your practice
  • Adding a signed or initialed entry for each treatment session, including the date and a description of the session
  • Documenting referrals to specialists or physicians, even if the patient declines the referral
  • Noting basic oral hygiene instructions and care tips given during an appointment. A simple “OHI given” or equivalent is acceptable.

Treatment abbreviations

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:

  • Printing a guide for every operatory or room where a dentist or dental hygienist might be accessing or editing records
  • Adding a list of abbreviations to your office manual
  • Using online office management tools to track abbreviations

Informed consent

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:

  • Document the educational conversation between yourself and the patient.
  • Both the dentist and patient should sign statements confirming that the educational conversation has taken place and that the patient has consented to care. Pre-written informed consent forms for common procedures may be available online or through your practice liability carrier, but you might need to modify them to be suit individual situations.

Outcomes of care

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:

  • Preventive
  • Operative, crown and bridge
  • Endodontic
  • Periodontic
  • Prosthetic
  • Surgical
  • Continuity of care
  • Overall patient care

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.