April 2005

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For the Record…

It is of vital importance that you document all interactions and procedures in your patient’s charts. According to Alan S. Rudakoff LLP, with Macleod Dixon, the average general dentist will be sued 6 to 10 times during their career, a specialist will be sued 12 to 20 times. Well detailed charts are essential in proving your innocence; the one with the most notes wins. The bottom line is you keep charts anyway, so why not make them as effective as possible?

Negligence Claims

All entries in your patient charts must meet certain criteria to withstand legal scrutiny. It doesn’t matter who makes an error, the mistake may have been made by a member of the administrative team, an assistant or hygienist, but it is the Dentist that will get sued. So, hire well, create great systems that minimize the chance of error, and then be sure that all team members are consistently following through on those systems. Negligence claims typically happen due to a breakdown in systems or outright carelessness.

Consider the following list of Do’s and Don’ts:

Do:

• At every appointment, ask each patient if there has been any change to their medical history. If there are any changes, be sure to document the change and have the patient sign and date their medical history form.
  
  
• At least once every 6 months, have your patients thoroughly review their medical history, make necessary changes and sign and date the form.
  
  
• Have the patient sign a Consent for Treatment.
  
  
• Have the patient sign indicating they have read and understand your office policy on the Personal Privacy Act.
  
  
• Complete a Periodontal Assessment at least once each year on every adult patient and discuss your findings with the patient.
  
  
• Document all information that is pertinent to patients’ future care.
  
  
• Always write in ink. You may want to use a different colour ink for restorative, hygiene and administrative. Example: restorative – black ink, hygiene – blue ink, and administrative – green ink. You may also want to use red ink for items you want to flag, such as medical alerts, pre-scheduled hygiene appointments, etc.
  
  
• Document all patient contact including items such as: treatment rendered, telephone calls - including care calls, gifts, cards or letters received from the patient, complaints and prescription requests.
  
  
• Include the complete date – month, day and year for each chart entry.
  
  
• Consider having team members initial every entry they make in a chart, even if it’s not required by law where you practice.
  
  
• Write legibly; print if your handwriting is difficult to read.
  
  
• Document all data immediately, delays lead to mistakes.
  
  
• When documenting information, describe the function in relation to the patients’ future care. For example, write, “referred to Bob Jones, DDS, for Periodontal therapy,” rather than just “referred to Bob Jones”.
  
  
• Whiteout should never be used on a chart. If a mistake is made, draw a single line through it and write “error” above it, with your initials and the date. Then write in the correct information.
  
  
• Standard abbreviations are fine. Keep a master-list of the abbreviations your office uses and have all team members use the same abbreviations.

Don’t:

• Correct, clarify, add to, change, modify or alter record data in any way after a lawsuit has been filed.
  
  
• White out, scribble over, cut off or obliterate a chart entry in any way.
  
  
• Write subjective comments about patients; rather quote patients’ words exactly.
  
  
• File charts until they have been checked for completeness.

If a patient does not accept the recommended treatment, write in their chart ‘patient has declined treatment’, and then have the patient put their initials or signature by the chart entry showing they chose to not have the treatment performed.

Have a policy and a system for documenting information that is consistently followed. If you are taken to court, documentation that is an exception to your typical method of recording information will not be as beneficial for fighting the case.

Ensure you are doing everything in your power to maintain thorough and accurate records. It will be well worth your time!

Action

Print out this newsletter, and with your team take a close look at your patient charts. Then, determine if there is anything else you can do, either from the above list of do’s and don’ts, or from other recommendations you have heard, that would help you make your records more complete. Do everything you possibly can to ensure that if you get sued your well documented records will disprove any allegations that are made.

About the Author

CoraMarie Clark, MBA is recognized as a highly effective dental practice strategist. She works with dentists that want to optimize their potential both personally and professionally. Her collaborative approach has helped teams develop dynamic competitive strategies and achieve high impact sustainable results.

If you would like to explore the possibility of having CoraMarie work with your Dental Practice or speak for your Association or Group, contact us today.

CoraMarie Clark
phone 403.686.6136
email coramarie@strategix-ltd.com
web strategix-ltd.com

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