The thoroughness of patients dental records are critical to the practice of dentistry. Dental records are regulated by federal and state laws in addition to participating provider contracts and professional licensing boards. It is imperative that a dental record contain accurate and detailed information pertaining to patient communications and treatment. Maintaining thorough patient charts protects both dentist and patient.
Consider the following fictionalized vignette:
Ima Dentist is a licensed dentist in California and has been in practice for 7 years. She formed a friendship with one of her patients, Heeza Patient, and slowly both realized that a spark was building between them during their office visits. Before becoming romantically involved, Ima decided it was best to terminate her professional relationship with Heeza. She referred Heeza to another dentist but did not document her decision process in his patient chart. Ima and Heeza began a sexual relationship weeks later. Eventually their relationship soured, and Ima ended the relationship and began to date someone else. Heeza did not want the relationship to end and was upset with Ima. Soon thereafter, Ima received notice from the Dental Board of California (DBC) that a complaint has been filed against her alleging sexual misconduct. Heeza’s chart is requested for review by the Board, and Ima’s career and reputation are threatened.
The above example underlines the importance of maintaining detailed patient charts. Thorough record keeping protects both patient and dentist, yet some dentists still choose either not to chart or to chart very briefly.
Documentation benefits the dentist by providing:
• Proof of the standard of care in the event that a patient’s record is requested, such as by a patient or after the Board receives a complaint.
• Protection against insurance company or Medicare audits.
• Protection in the event of catastrophic loss such as theft, fire, earthquake.
• Proof of continuity of care to a patient when a patient is referred to another professional such as an orthodontist, when a considerable period of time elapses between patient appointments, or if a patient is transferred to a new dental provider such as in the event of the unanticipated death/illness of the original dentist.
• Protection in the event of legal proceedings between dentist and patient.
• Protection against charting or billing errors.
Documentation benefits the patient by providing:
• Treatment details for third-party reimbursement.
• Reminders to the practitioner of a patient’s medical history and treatment plan.
• Continuity of care to the patient when a patient is referred to another professional, when a considerable period of time elapses between patient appointments, or if a patient is transferred to a different dentist in the event of the unanticipated death/illness of the original dentist.
• Information to legal authorities as needed to identify a deceased patient in a forensic investigation.
So why do some dentists choose either not to chart or to keep minimal documentation?
Some dentists believe that a dental assistant is responsible for the accuracy or thoroughness of dental records. Others reason that only the briefest of SOAP notes is sufficient. Some may believe that keeping records that includes information aside from SOAP notes could violate a client’s confidentiality if records are sought by third parties, such as insurers. Others feel there is nothing new to add to a patient’s chart after an appointment that does not result in dental treatment. Some erroneously assume that disciplinary action will never occur to them and, if it ever did, mistakenly believe that patient dental records could be cobbled together at that time. Some dentists also believe that they will accurately remember relevant case details if ever needed, but it is important to note that a complaint may take several months to review and/or resolve.
The details in a patient’s dental record is of critical importance when a licensing board decides whether to pursue disciplinary action after receiving a patient’s complaint. If it’s not in the record, it didn’t happen. Dentists must understand the laws, standards, and state licensing board requirements pertaining to patient medical records. If a patient visits, visit the patient’s chart.
We are here to help.
If you are a dentist facing disciplinary action, it is imperative to enlist the assistance of an experienced licensing attorney at the earliest stage of the disciplinary process. The Law Offices of Lucy S. McAllister are here to help. We understand the unique legal complexities facing dentists. We have the knowledge and experience to craft a comprehensive strategy and are dedicated to navigating your specific case through the disciplinary process to best defend your professional interests.
The Law Offices of Lucy S. McAllister have successfully represented a wide range of California licensed professionals including dentists, nurses, physicians, pharmacists, chiropractors, and mental health practitioners. We are experienced in handling all types of licensing issues. Let us help you protect your professional license, your reputation, and your livelihood.
For additional information or to schedule a consultation on a professional licensing issue, please contact us today at (877) 280-9944.
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