department of health professions virginia board of dentistry recordkeeping - beyond the regulatory...

www.dhp.virginia.gov

Department of Health Professions

Virginia Board of Dentistry

RECORDKEEPING -BEYOND THE REGULATORY

REQUIREMENT

Roanoke Valley Dental Society

November 6, 2007



Recordkeeping is the foundation for good patient care and good communications about your practice.



Good records support billing practices and demonstrate your knowledge of :– your patient, – the practice of dentistry and – the laws and regulations

governing that practice.



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.



A complete record will address every aspect of the practice of dentistry:

»Evaluation»Diagnosis»Prevention»Treatment

Or explain why it doesn’t



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?



Recordkeeping Requirements: the minimum standard

1. Patient’s name and date of treatment

2. Updated health history3. Diagnosis and treatment

rendered



4. List of drugs prescribed, administered, dispensed and the quantity

5. Radiographs6. Patient financial records7. Name of dentist and dental

hygienist providing service



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



• 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.



An incomplete record undermines care and communications.

Consider this example of incomplete treatment notes:



• “18” noted in the TOOTH column• No entry in SURFACE column• No entry in SHADE column• No entry in AN column



• Entry in TREATMENT column: “ All Bond II AmalgamCore – LTP Fair to poor. Incomplete Endo.”

• Billing statement noted “CORP**02950 Core Buildup, Inc. Pins(#18)



What do you know?

What do you want to know?

What do you think the complaint was?



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



What the record didn’t include was:

• who treated the patient• a diagnosis• medical history • an adequate description of the

treatment rendered• x-rays



What do you think should have

been the outcome of the complaint?



A complete patient record

1. Patient identified on each document

2. Reason for visit3. Review medical/dental history4. Patient’s chief complaint5. Symptoms



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



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



17. Items given to patient 18. Laboratory work orders19. Financial records



Remember, if it is not written down – it did not happen.

Consider this example of a complete treatment note:



Pt presented for consult re dental implants

Pt reports having pain, odor and not able to chew on #30, has RC/crown



#30 presents with abcess, bone loss, mobility, pocketing, bleeding upon probing, rct, porcelain fused to metal crown



TX options:1. Extract 30/graft bone/implant2. Extract 30/graft bone/fixed bridge

29-31/implants



Alternatives, fees, estimated insurance and complications were discussed.

Consent obtained



The record included:• Medical history• Xrays and photos• Detailed notes regarding the

extraction and bone grafting• Drugs administered



• Note of home care instructions and products given to pt

• Meds dispensed and prescribed• Appt to check tx• Charges and billing transactions



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.



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



• You own the record but must provide copies

• You must provide itemized billing statements when requested



• You must give notice by mail and in a newspaper before you transfer records when closing, selling or relocating to current patients



• Confidentiality must be addressed when disposing of records as well as all other times



www.dhp.virginia.gov/dentistry

Statutes Bulletins Regulations Announcements Forms License Look-up Calendar Guidance Documents Recent Case Decisions

Board of DentistryWEB Page



Board of Dentistry

9960 Mayland Drive, Suite 300Richmond, VA 23233-1463Phone: (804) 367-4538Fax: (804) 527-4428Complaints: (800) 533-1560Email: [email protected]

department of health professions virginia board of dentistry recordkeeping - beyond the regulatory...

Documents

column slide

service slide

doesnt slide

crown slide

updated health history

treatment column

date of treatment

practice of dentistry