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Clinical Chart Documentation Guidelines

May 17, 2021 3127

Patient record

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:

  • A description of the patient’s original condition.
  • Your diagnosis and treatment plan.
  • Progress notes on the treatment performed and the results of that treatment.
  • Patient’s personal and financial information.
  • Health history (all questions answered) and regular updates.
  • The medical history should record all current medications and medical treatment. A proactive (“Yes” — “No”) format is recommended.
  • Dental history.
  • Vital and diagnostic signs.
  • Oral cancer screening.
  • TMJ evaluation.
  • Periodontal evaluation.
  • Diagnostic test findings and exam notes.
  • Consultant reports and reports to and from specialists and physicians.
  • Notes describing complaints or confrontations.
  • Notes about rescheduled, missed or canceled appointments.
  • Informed consent/informed refusal discussions and forms.
  • Models.
  • All radiographs taken at intervals appropriate to patient’s condition.
  • All written authorizations to release records.
  • Correspondence to and from the patient, inclusive of phone calls, emails, voice messages, letters and face-to-face conversations.

Health history

  • Make sure to note any conditions requiring premedication, history of infectious disease or illness, allergies and any tobacco, drug or alcohol usage.
  • The medical history should record information pertaining to general health and appearance, systemic disease, allergies and reactions to anesthetics.
  • Have patients review and update their health history form at every visit as well as sign and date it. You should also initial and date the form.
  • When reviewing the health history with the patient, question the patient regarding any areas of concern or speculation. Write the clarifications on the health history form along with the date of the discussion.

Medications

Document any medications given, recommended or prescribed in the record. Documentation of complete prescription information should include:

  • The type and amount of medication, including name, strength, number of tablets, dosage level and time interval and the number of refills if any.
  • The date and name of pharmacy (if applicable).
  • The use of anesthetics or analgesics during treatment if applicable.
  • If the patient declines anesthesia or analgesics, it should be noted.

Treatment Information

  • Note examples of pertinent information include the patient’s current dental complaint, current oral condition by examination and radiograph findings.
  • Document the patient’s expectations and whether those expectations are realistic.
  • Note conversations with the patient’s previous dentists and any patient complaints about a previous dentist’s treatment in a factual manner.
  • Document the patient’s baseline condition, including existing restorations, oral health status, periodontal condition, occlusion and TMJ evaluation, blood pressure and pulse rate.

Treatment planning

  • Before initiating any treatment, the patient record should reflect a diagnosis of the patient’s problem based on the clinical exam findings and the medical and dental histories.
  • Document the treatment plan for the diagnosed condition including all radiographs and models used and a summary of what you learned from them.
  • Give a complete description of the dental treatment to be performed and how the treatment plan will address the problems identified in your diagnosis.
  • Address whether the diagnosis indicates more than one treatment alternative, with all alternatives noted in the record.
  • Incorporate whether or not you chose to consider a common alternative (e.g., an implant in a restorative case), summarizing your reasons for that decision and whether all or any part of the planned treatment requires referral to one or more specialists, along with the names and specialties of those involved.
  • Note the patient’s expectations: costs, and esthetics.
  • Note the patient’s concern(s) or needs about a specific treatment outcome (e.g., when a fashion model receives restorative treatment or a professional musician who plays a wind instrument receives orthodontic treatment).
  • When finances affect the patient’s treatment decisions, consequences and risks should be noted and informed refusal should be obtained.
  • Note discussions about treatment limitations, and life expectancy of treatment.
  • Document in the chart all discussions regarding future treatment needed, including any requests for a guarantee of treatment and your response (treatment should never be guaranteed).

Failed appointments

  • Document the conversation in the patient’s chart.
  • When you are not successful in reaching the patient, record the number of attempts you made including the dates and times of those calls and the telephone number, from the patient’s chart, that you called.
  • Note any messages you may have left and with whom.
  • Note any letters or other correspondence sent to patient. If letters are sent, keep copies.

Documenting interactions with an angry patient

  • Keep a written record of all your interactions with difficult patients.
  • Use quotation marks for patient’s actual words.
  • Use objective rather than subjective language.
  • Do not add to or delete from the patient’s chart – if changes must be made, strike through the language meant to be changed, add new language, initial and date.

Patient dictating treatment

  • Document when a patient demands treatment that you believe to be inappropriate.
  • Explain why you believe it is inappropriate.
  • Make it clear that the decision is the patient’s, not yours.
  • Document why the patient has made the request (often financial) and obtain informed refusal, if appropriate.

Changes to patient information

  • Note in the chart any information that will affect either your business or therapeutic relationship.
  • Changes or additions to initial personal or financial information (patients may have changed employers, insurance companies, address or marital status), changes in patient’s behavior, patterns of noncompliance or prescription requests and any new dental problems.

Oral cancer screening

  • As part of every patient’s oral exam appointment, perform an oral cancer screening. Inspect the head, neck, lips, floor of the mouth, front and sides of the tongue and soft and hard palates.
  • Document your findings in the patient’s chart, including the presence of no symptoms.
  • Dentists must either biopsy any suspicious tissue or refer the patient for biopsy in a timely manner.
  • Document your biopsy findings or referral.
  • Document all follow-ups with patient and referral practitioner.

Periodontal probing

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 date of the examination.
  • All pocket depths, including those within normal limits.
  • Description of gingival tissue health.
  • Identification of areas of tissue pathology (such as inadequately attached gingiva).
  • Areas of bleeding or other pathology noted on probing (e.g. suppuration and tooth mobility).
  • Mobility

SOAP

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.

  • S – Symptoms and subjective observations or the patient’s chief complaint. This is information that the patient gives, including the patient’s chief complaint or obvious symptoms.
  • O – Objective findings or the dentist’s observations. Evaluate the patient’s condition. This includes health history, vital signs, diagnostic aids and other dental or medical consultation.
  • A – Assessment and advice, i.e., the diagnosis and informed consent discussion. This includes the diagnosis, alternatives to recommended treatment and informed consent/refusal discussion.
  • P – Plan or procedure, the actual treatment plan and the treatment performed. This states what you will do to address each complaint. This needs to include materials, anesthesia, tooth number, medications and any referrals.

Discussions with your professional liability carrier:

  • When treatment does not go as planned, document what happened and your course of action to resolve the problem.
  • Keep documentation of discussions between you and your professional liability carrier separate from the patient’s record. If these discussions are included in the patient file, they are part of the patient record and can be used against you.
  • If you are contracted with any dental benefit plans, be sure to review their provider handbook/contract to review their chart documentation requirements.

Disclaimer:

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.