One of the most effective ways to stay out of trouble with the Board of Dentistry, American Dental Association (ADA), and dental insurance companies is to understand some of the top reasons why dentists get into hot water. The ADA published a list of what causes dentists the greatest liability when it comes to record keeping.
As you might imagine, failure to document the treatment plan is at the top of the list. Whether you write your own chart notes or review what was written by your clinical team, it’s critical to make sure all recommended treatment is documented thoroughly—clearly showing the reasons for treatment, and when treatment is rendered clearly writing what was done.
The next group on the list involves fundamental record keeping: updating health histories, getting informed consents, documenting patient complaints and non-compliance issues, and making sure notes are legible. Consider the systems you have in place and how you can make those systems more effective. Incomplete records will work against you if you ever face a Board compliant or liability issue.
Finally, even though it may go without saying, an unfortunate number of dentists get in trouble for altering chart notes. The ADA recommends that dentists never leave space between entries. You do not want to give the appearance that you plan to add to the notes at a later date. Also, avoid whiting out notes, and do not cross out entries with more than just a thin line (make sure the entry is still readable to prove you are not covering up something important).
Since chart notes are so critical for defending what you do chair-side, please consider how you can make your process even better. By expending extra effort right now to do it right, you will save yourself a lot of headache and expense in the long term.