The patient record is the history of your therapeutic relationship with your patient. It gives you all of the information you need to continue treating that patient appropriately. Complete records should include:
Document any medications given, recommended or prescribed in the record. Documentation of complete prescription information should include:
The evaluation and documentation of a patient’s periodontal health is part of the comprehensive dental examination. Current standards call for full-mouth periodontal probing at each hygiene recall visit, and the absence of that information in the chart might be construed as failure to conduct the periodontal examination. The documentation should include:
The simple record-keeping system SOAP is a good way to document each visit. This method provides for patient complaints, the nature of the examination, significant findings, diagnosis and planning. Formatting records in this fashion not only helps in the defense of a dentist’s treatment but also makes for a more thorough record upon which to evaluate a patient’s condition over time.
In developing this resource, CDA researched and talked to experts in the field of dentistry, law and insurance claims. However, the ideas and suggestions contained in this resource represent experience and opinions of CDA. There are no guarantees that any particular idea or suggestion will work in every situation. The ideas and suggestions contained in this resource are not legal opinion and should not be relied on as a substitute for legal advice. For legal advice specific to your practice, you must consult an attorney. Lists are not exhaustive of issues to be addressed and suggestions may not be applicable to every situation.