Kansas Dental
Board Issues a Reminder on Record Keeping
Requirements
In the
July Kansas Dental Board Newsletter, the Kansas
Dental Board issued a reminder on the dental record
keeping requirements.
"Questions often arise
about record keeping requirements," the newsletter
says. "The basic requirements for patient records
are listed in K.A.R. 71-1-14"
Read the requirements
We specifically
asked the Dental Board if there were any particular
issues they were finding our were going to begin to
view under additional scrutiny in the future.
The board indicated that there are some dentists who
are not keeping as good of records as they need to
be keeping. In many cases, the board will come
into an office to investigate an issue and will find
that the dentist is in violation of K.A.R. 71-1-14.
Record is important component to address
a patient complaint
When a complaint
is made to the dental board, the patient record
becomes a vitally important document that is used
when addressing the complaint. It is the dentist’s
and dental hygienist’s report made at the time of
treatment. The
dental record entries document
patient concern/reason for appt., findings,
diagnoses, treatments and plans for treatment as
well as Information given about possible outcomes,
and patient progress. While the primary purpose of
good record keeping is to facilitate good patient
treatment, it is also the licensed dental
professional’s best defense.
The
record must be legible
As stated in
the regulation, the record must be legible. The
record can be hand written, typed or kept in
computer entry and may include images such as
radiographs, photographs, graphs and charts. The
entries may be done in a SOAP (Subjective,
Objective, Assessment, Plan) format, but this is not
a requirement. A narrative entry can contain all of
the required information as well. The length and
detail of record entries will vary based on
individual patient situations, treatment done, and
the practice preferences of the licensee. The
minimum requirements are those listed in the dental
practice act however other pertinent information can
be included.
Entries must be dated
and Codes may change over time
The
entries must be dated. The requirement for quantity
and strength of medication administered includes
local anesthetic (for example: anesthetic used,
number of carpules, volume and percent or mg dosage
). Lists of filed insurance reimbursement codes or
their word definitions alone do not necessarily make
an adequate record because those codes do not
usually provide specific diagnostic information,
information about medications, or any treatment
particulars (some medical codes are diagnosis
defining). In addition, the descriptors for codes
are regularly reviewed by the American Dental
Association and can change, so the description of a
code today (or the day it is reviewed) may differ in
a meaningful way from the description of that code
when it was recorded. Codes are also deleted and
added. For example, a record entry of “120, 1110,
Plan: 2386 #3. In this example, not only is no
diagnosis recorded, but the descriptor for 1110
(Nomenclature: prophylaxis - adult) has changed over
time and the code 2386 (which was a code for a
posterior composite on a permanent tooth) is no
longer used.
Entering a report, using words,
of the actual diagnosis(es), treatment performed,
and so on is much more comprehensible over time than
using reimbursement codes alone. For example, a
record entry in a patient folder or in the patient’s
computer file that is dated and that says only “#4
MO Comp” provides no information about diagnosis
(eg. Caries, defective restoration, crack, cosmetic
concern, contact closure, etc.). The reader would
have to assume that no local anesthetic was used.
There is no information about alternatives or
possible sequelae. Of course, the diagnosis may have
been recorded in a previous entry, but if it was
not, the record does not meet the minimum
requirements.
Similarly an entry that states
only “#3 TE, anes, Rx” lacks diagnosis, information
about anesthetic , any information about
alternatives or post operative instructions or
required information about the prescription
strength, dosage, etc. A progress notes entry
that states: “Ex, 4 BW, Proph, no change” gives no
particular diagnostic information. It relies totally
on information recorded at a previous visit for
completeness. Even a longer progress notes entry can
leave out required information if it stands alone.
For example, “Ex,Pro,fl, needs RC #4” as the only
record entry gives no information about diagnosis,
any tests done on #4, any other exam findings of the
soft or hard tissues. Of course, in most patient
records, the progress note written entries (either
in a paper or electronic record) do not stand alone.
There are often periodontal charts, images, test
results, etc. included. Each dental record must meet
the requirements listed in the Dental Practice Act,
but may contain more information if the licensee
chooses to do so to facilitate the
treatment for
the patient.
The board is sometimes asked if
a record must have this or that particular form or
item, or how often a particular form or item must be
updated. Some licensees have expressed interest in a
list or protocol developed by the board. The board
recognizes that practice needs and preferences vary,
and to date has limited requirements to those now in
the Dental Practice Act. You may wish to develop a
list or protocol that fits your needs and those of
your patients while
adhering to the minimum
standards that are listed in the Practice Act. There
are many resources available from schools and
universities, professional associations, liability
insurers and consultants that may be helpful.
When you review your record keeping practices,
consider starting with these two questions:
Do the records meet the requirements set forth in
the Dental Practice Act?
Are the records adequate
to accurately report the treatment process if they
are needed to stand in defense or clarify an issue
that might be raised about treatment?
|
