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Top Ten Best Practices for Record Keeping

Dental Risk Prevention: Communicating and Record Keeping in the Dental Practice

Top Ten Best Practices for Record Keeping

  1. Patient records must be consistent.  If your record varies in degree of detail from one entry to the next, misleading implications may be made about your quality of care.
  2. All boxes, blanks, or checklists in the record must be completed.  If this is not done, it gives the impression a task, procedure, or item was not performed or completed.  If a question does not apply to the patient, use “not applicable” or other appropriate term.
  3. Avoid words that are vague or may have several meanings.  Ambiguous words such as reassured, appear, or inadvertently may misrepresent your actual objective intent and/or clinical findings.
  4. Read and reread what you write.  This ensures your progress notes are correct and cannot be interpreted in more than one way.  And most of all it ensures your written word conveys your accurate intent.
  5. Be sure your handwriting is legible or there are no typographical errors if using electronic patient records.  Illegible or poorly typed progress notes may lead to misinterpretation of the care you provided impacting patient safety or the continuity of care.
  6. Avoid inaccurate or deliberately misleading statements.  Not maintaining accurate, truthful records lessens the value of the care you rendered and may jeopardize patient safety.
  7. Document complications, mishaps, or unusual occurrences in a concise, objective manner.  Subjectivity lessens the credibility of your records.  In some states, complete lack of documentation in the patient record regarding patient injury or an adverse event may jeopardize the legal privilege.
  8. Limit your description of an occurrence to the facts and resist the temptation to explain, rationalize, or argue your case in the records.  Remember, the primary purpose of the record is for patient care; your records should not be self-serving, even if litigation is anticipated.  All subjective information and opinions may be provided to your professional liability carrier or legal representative.
  9. Avoid expressions that imply disapproval or a negative value judgment about a patient.  Negative remarks or opinions lessen the value of your records as well as your professional credibility.  Patient behavior or noncompliance should be recorded in an objective manner.
  10. Never destroy, rewrite or replace a prior record.  Rely upon standard acceptable practices when correcting errors.  For written records, draw one line through the error and initial it.  Errors discovered the next day (written or electronic) should be corrected by writing a new entry.  Improperly correcting mistakes casts unnecessary suspicion.

This article is informational only and not intended as a substitute for legal advice. Please refer to the state statutes in the jurisdiction where you practice or contact your attorney for specific information regarding the laws and rules in your state governing record keeping.

For additional information on in-office training or to order a copy of Dental Risk Prevention or Dental Risk Prevention for Auxiliaries, please call us at 904-573-2232.