department of health professions virginia board of dentistry recordkeeping - beyond the regulatory...
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Department of Health Professions
Virginia Board of Dentistry
RECORDKEEPING -BEYOND THE REGULATORY
REQUIREMENT
Roanoke Valley Dental Society
November 6, 2007
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Department of Health Professions
Recordkeeping is the foundation for good patient care and good communications about your practice.
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Department of Health Professions
Good records support billing practices and demonstrate your knowledge of :– your patient, – the practice of dentistry and – the laws and regulations
governing that practice.
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Department of Health Professions
Dentistry means the evaluation, diagnosis, prevention, and treatment, through surgical, non-surgical or related procedures, of diseases, disorders, and conditions of the oral cavity and the maxillofacial, adjacent and associated structures and their impact on the human body.
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Department of Health Professions
A complete record will address every aspect of the practice of dentistry:
»Evaluation»Diagnosis»Prevention»Treatment
Or explain why it doesn’t
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Department of Health Professions
What is a record?
Is it the file you have identified as belonging to the patient and only what you put in that file?
Is it each piece of paper or document you create or collect on the patient?
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Department of Health Professions
Recordkeeping Requirements: the minimum standard
1. Patient’s name and date of treatment
2. Updated health history3. Diagnosis and treatment
rendered
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Department of Health Professions
4. List of drugs prescribed, administered, dispensed and the quantity
5. Radiographs6. Patient financial records7. Name of dentist and dental
hygienist providing service
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Department of Health Professions
8. Laboratory work orders •Name and address of the lab•Patient’s name or initials or ID #•Date the order was written•Description of work, including diagrams if needed
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Department of Health Professions
• the type and quality of materials to be used
•Signature and address of the dentist
Records must be kept for not less than 3 years following the most recent date of service for the Board.
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Department of Health Professions
An incomplete record undermines care and communications.
Consider this example of incomplete treatment notes:
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Department of Health Professions
• “18” noted in the TOOTH column• No entry in SURFACE column• No entry in SHADE column• No entry in AN column
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Department of Health Professions
• Entry in TREATMENT column: “ All Bond II AmalgamCore – LTP Fair to poor. Incomplete Endo.”
• Billing statement noted “CORP**02950 Core Buildup, Inc. Pins(#18)
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Department of Health Professions
What do you know?
What do you want to know?
What do you think the complaint was?
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Department of Health Professions
The complaint was that the dentist billed for a core build up on #18 when he only placed an amalgam filling in a hole in a crown
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Department of Health Professions
What the record didn’t include was:
• who treated the patient• a diagnosis• medical history • an adequate description of the
treatment rendered• x-rays
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Department of Health Professions
What do you think should have
been the outcome of the complaint?
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Department of Health Professions
A complete patient record
1. Patient identified on each document
2. Reason for visit3. Review medical/dental history4. Patient’s chief complaint5. Symptoms
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Department of Health Professions
6. Visual findings 7. Diagnostic records brought, needed or taken
8. X-Rays, Digital Images, Pictures
9. Dentist’s examination findings
10. Dentist’s diagnosis 11. Recommended treatment
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Department of Health Professions
12. Treatment choices discussed
13. Pt consent for treatment14. Treatment rendered
15. Drugs administered, dispensed,
prescribed16. Name of dentist, dental
hygienist and assistant who provided service
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Department of Health Professions
17. Items given to patient 18. Laboratory work orders19. Financial records
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Department of Health Professions
Remember, if it is not written down – it did not happen.
Consider this example of a complete treatment note:
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Department of Health Professions
Pt presented for consult re dental implants
Pt reports having pain, odor and not able to chew on #30, has RC/crown
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Department of Health Professions
#30 presents with abcess, bone loss, mobility, pocketing, bleeding upon probing, rct, porcelain fused to metal crown
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Department of Health Professions
TX options:1. Extract 30/graft bone/implant2. Extract 30/graft bone/fixed bridge
29-31/implants
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Department of Health Professions
Alternatives, fees, estimated insurance and complications were discussed.
Consent obtained
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Department of Health Professions
The record included:• Medical history• Xrays and photos• Detailed notes regarding the
extraction and bone grafting• Drugs administered
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Department of Health Professions
• Note of home care instructions and products given to pt
• Meds dispensed and prescribed• Appt to check tx• Charges and billing transactions
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Department of Health Professions
The record did not become an issue in this complaint which was about what the pt agreed to and the actual cost vs the estimate.
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Department of Health Professions
About those records:
• x-rays should be of diagnostic quality and you are required to keep them
• Can be stored electronically • paper copies are not required if the
record is unalterable
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Department of Health Professions
• You own the record but must provide copies
• You must provide itemized billing statements when requested
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Department of Health Professions
• You must give notice by mail and in a newspaper before you transfer records when closing, selling or relocating to current patients
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Department of Health Professions
• Confidentiality must be addressed when disposing of records as well as all other times
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Department of Health Professions
www.dhp.virginia.gov/dentistry
Statutes Bulletins Regulations Announcements Forms License Look-up Calendar Guidance Documents Recent Case Decisions
Board of DentistryWEB Page
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Department of Health Professions
Board of Dentistry
9960 Mayland Drive, Suite 300Richmond, VA 23233-1463Phone: (804) 367-4538Fax: (804) 527-4428Complaints: (800) 533-1560Email: denbd@dhp.virginia.gov
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