If you ever find yourself involved in a malpractice dispute with one of your dental patients, the dental records you’ve kept on that patient – if maintained well – will be invaluable to you. That’s because the dental record is the actual record of treatment provided to the patient, so its appearance is extremely important to your defense.
What a Dental Record Should Be
A dental record should describe the complete history, evaluation diagnosis, treatment and care of a patient (in this way it is of maximum value in terms of its accuracy and credibility, particularly when used in legal proceedings). The dental record should be precise, neat, complete and legible, and it should be written so that any other dentist who has a reason to pick up the record knows exactly what has been done for the patient, when it has been done, and why. Ultimately, a good rule of thumb to remember regarding your patient’s dental records, especially as it relates to legal implications: if you didn’t chart it, you didn’t do it.
Appropriately Documenting the Dental Record
Entries in the dental record must match precisely and coincide directly with treatment, must be written contemporaneously, and should be written legibly in ink or transcribed. Be sure to use a consistent style for your entries. If your records are ever challenged in court, consistency will impart credibility to your records and will demonstrate your professionalism in maintaining them. You must accurately record both positive and negative findings, and enter the time and date of all entries, signing each one. All entries should follow sequentially; do not leave any spaces between them.
If you make an incorrect entry, cross it out by drawing a single line through it, writing the word “error,” and initialing and dating the correction. Do not, under any circumstances, use Wite-Out or erase an entry. Both techniques suggest you have something to hide. Each correction should be made as it happens with an explanation for the correction to preserve the record’s integrity. Be sure to record telephone calls, missed appointments and any failure by the patient to accept or follow instructions. This type of information will be helpful in defending a future court action.
Always be sure to record your observations in an objective and dispassionate manner. The dental record is not the place to settle disputes, assign blame, or write derogatory remarks. Such superfluous entries seem to communicate a lack of professionalism and may raise doubts about the record’s overall credibility.
Stay tuned for more on dental records, including guidelines on how long to retain them and what you need to do to release them.