Chart Documentation Guidelines
Comprehensive patient records are crucial to patient care and practice success.
According to The Dentists Insurance Company (TDIC), records should include an objective record of facts, impressions, clinical judgment, and treatment. Entries should be detailed enough anyone with similar experience would be able to read your notes and understand the treatment provided or planned and why. Inappropriate subjective notes should be avoided.
Remember – Details Count!
Timeliness. Record patient notes in a timely manner in chronological order. The author of the note should list their first initial and full last name for each entry. Best practice would be to have notes entered before the end of the day, at the latest.
Corrections. Correct electronic records through an addendum. Correct handwritten records by drawing a line through the original entry and initialing.
Abbreviations. Dental practices should author an approved list of abbreviations for charting purposes. Only approved abbreviations should be used, all other words need to be spelled out.
Tracking Diagnostic Tests. Track diagnostic tests or any pertinent information and referrals to a specialist(s). Note contact made with the patient regarding the results and next steps.
Patient Contacts. Record all patient contacts in the patient record. This includes clinical interaction as well as phone conversations. Note when a patient calls with questions, cancels an appointment(s), or needs to reschedule.
Patient Termination. In the unfortunate situation of terminating a patient, provide a certified letter with a promise to treat emergencies for the next 30 days to allow the patient to find an alternative provider.
Chart Retention. Please refer to your state dental board for retention guidelines in your state.
Essential Elements of a Good Dental Chart
Enter pertinent information and update annually or when information changes.
- Pertinent information includes but is not limited to – address, patient status and classification, preferred contact method, insurance, secondary insurance, recare cycle (3, 4, or 6 months), and associated family members.
Information should be completed upon the initial visit and reviewed verbally at each future visit. New signatures should be obtained annually or whenever a health change is communicated.
- Medical emergency warnings and concerns should be noted in the health history module as well as in the Alerts module.
- Update and collect the patient or responsible party(s)’ signature(s) and dates annually; more frequently if changes are noted.
Any item(s) requiring immediate attention should be noted in the Alerts module of your practice management software.
- Items such as allergies or medication(s) impacting dental treatment should be noted in the health history as well as the Alerts module. A latex allergy or an anti-coagulant medication would be examples of items listed as an Alert.
- Patient classification could also be listed as an Alert. For example, it is recommended to schedule “red” patients, those who habitually break or cancel appointments, for same-day procedures only.
These agreements include but are not limited to HIPAA, financial agreements, consent for treatment, and treatment plans.
- Based upon your practice management software and electronic signature capturing device, these documents can be captured and saved or printed, manually signed, and scanned into your practice management software system.
Posted procedures or items of purchase as well as payments, insurance reimbursements, and adjustments should be current.
All radiographs, photos, CBCT, and CAD/CAM images should be attached to the record.
Clinical notes should be objective and consistent, following one of the formats listed below.
Clinical/Chart Note Format
- PARQ (“Procedure” to be performed, “alternative” to the procedure – including no treatment at all, discussion of the “risks” involved with treatment and avoiding or delaying treatment, and an opportunity to answer any “question” a patient may have).
- SOAP (“Subjective” findings, “objective” findings, “assessment” or diagnosis, and “plan”).
Hard & Soft Tissue Examinations
- The documentation of the examination must be comprehensive. Head and neck, TMJ, soft and hard tissue, periodontal probing, oral cancer screening, etc. An entry, which states “exam,” does not tell the procedure.
Supporting Clinical Examinations
- Document all of the positive findings which are essential to the diagnosis.
- Document all of the negative findings when it is customary to do so (i.e. “No sign of infection” or “Pain has resolved”).
Posted Treatment (Walk-Out)
Post completed procedures and purchased products to the ledger. Provide a walk-out statement to the patient reflecting the services and products provided.
Enter diagnosed treatment, including alternative options, in the practice management software:
- Whenever possible, any and all treatment should be sequenced in order of highest priority with associated scheduling parameters.
- It is a best practice to have a treatment plan signed and saved in your practice management system. It may also be beneficial to document patient responses to the treatment plan.
- Treatment plans should provide an estimate including the full office fee and anticipated insurance benefits when available. The patient’s signature on the treatment plan acknowledges their understanding the estimate is not a guarantee and the patient is ultimately responsible for payment.
Referral Recommendations or Information
All referrals to outside dental or health professionals, or patient summary information from those sources, should be documented. Note the contact made with the patient regarding the results and next steps.