Written by Kristen C. Close, RDH, BS, and Kimberly S. Gillen, RDH Wednesday, 30 November 2005 19:00
Does your documentation reflect what you really do? It has been said many times, “If it isn’t written, it didn’t happen.” Medical records are unquestionably the single most important evidence for you in the event of a malpractice claim or other inquiry concerning patient care. On the other hand, your documentation style could cause you to face your state board of dentistry, and ultimately could result in thousands of dollars in fines if it is found to be in violation.
According to Diane Glascoe, RDH, BS, at the 2005 RDH Under One Roof Conference, 2 of the top 5 most frequent lawsuits against dental practices relate to medical record keeping.1 In the state of Florida, approximately 9 out of every 10 recent complaints include an issue(s) with a provider’s failure to meet current, minimum documentation standards.2 Therefore, in today’s litigious society and ever-changing healthcare environment, the need for accurate and comprehensive medical records must never be underestimated.
Achieving records that reflect what you as the professional have performed and the high standard of care and service put forth for your patients should be done systematically and consistently as well as discussed and agreed upon by the entire office team. Many dental textbooks and journals make reference to acronyms such as SOAP—subjective, objective, assessment, and plan—as one method of consistent record-keeping assurance. Also, regularly attending legally related continuing education courses and staying abreast of current, ongoing trends among the various state dental boards will help a practitioner better understand how to avoid potential sources of litigation.
The Florida Board of Dentistry recommends, “developing a working knowledge of BOD rules and Florida law [to] help dentists create a wall of defense against disciplinary action and costly fines.”3 While recognizing that diligent record keeping is an integral part of dentistry and promotes good practice, various state boards of dentistry nevertheless offer little guidance to providers on how records should be written. The ambiguity arises because much of the documentation standards are dictated by case law rather than regulatory law; only after a ruling has been made is a precedent set by which all other providers should abide.
Due to the recent rise in complaints against dental hygienists (and also against dental assistants in some states), all dental professionals, not just dentists, will find the information contained in this article to be a valuable resource as to how one can protect his or her professional license and certification. The goal of this article is to consolidate and summarize much of the current available information and serve as an overall risk management reference for today’s dental practices.
The first step in creating legally defensible patient charts is legibility. While it is not necessary to have attended parochial grade school in order to have developed the skill of acceptable penmanship, it is of utmost necessity that one writes clearly so that outside readers can understand the records. Character printing, as opposed to cursive or calligraphy-type handwriting, is recommended. Chart entries must always be made in permanent black ink, in chronological, sequential order, and dated. Overall, patient records must be kept free and clean from contamination and smudges in order to be read and photocopied easily. Each and every team member who participates in recording remarks or entries into patients’ permanent medical files must commit to writing legibly and must agree to sign and/or initial all notes for reference sake.
Next, the second responsibility of the dental professional in patient record maintenance is to guarantee that a patient’s record is credible. This encompasses several traits, the first regarding the use of abbreviations. Abbreviations are acceptable as long as they are standardized. For example, BOP, FMX, pt, and MOD are commonly used and understood for their meaning, whereas BOS would not be considered standard record-keeping terminology. Be advised that excessive use of abbreviations may be perceived upon legal review as taking a hurried approach to chart entry, thus providers should take care to ensure that the use of abbreviations is prudent. The use of jargon or slang language is inappropriate at all times and absolutely does not have any place in legal medical records.
In order to preserve further a credible standard of record keeping, one should be mindful of chart note alterations or corrections. According to Bramley,4 “alterations should be signed… and dated, with the altered entry scored out but still left legible. Legislation does not actually demand these requirements, but the clinician should remember the test that courts use in negligence cases is whether the clinician has been reasonable.”4 Correction fluid or completely blacked-out areas must never be used, as juries tend to perceive such actions as fraudulent or deceptive in nature. Similarly, one should avoid marking in margins or writing below the last line on a page. Skipping lines is a practice that should also be avoided, if at all possible. If not possible, 2 approaches are acceptable to indicate a necessary blank space in a patient’s chart: either a single, straight line filling the blank space or an entire section cross-out with an x. Adopting a uniform system for making corrections is especially important to today’s dental practices; inappropriate alteration of medical records could result in disciplinary action, at maximum even criminal punishment (falsification of legal documents). Refer to the comparison below of incorrect versus correct corrective techniques taken in a patient chart:
(1) Example of an incorrect entry (black-out method): 01/01/05 Ex, n , Pro, Perio Maint, 4 BWX …
(2) Example of a correct entry with correction (single-line score and initial method): 01/01/05 Ex, Pro01/01/05 (KC), Perio Maint, 4 BWX …
Addendums may also be made when charting patient records, as long as these types of entries are indicated as such, separately dated, and signed at the time of the addition. A clinician often will find an amendment to be particularly necessary after having some dialogue with a patient. Glascoe, among others, recommends the use of quotation marks as a highly effective technique to chart direct patient conversation, complaints, concerns, or comments.1 For example, refer to the following chart entries below:
(1) Example of correct entry with direct patient quotation: 01/01/05 Re-eval perio. Pt reports “My gums don’t hurt anymore and seem to be bleeding less.” FMP reveals 1-2 mm improvement. All pockets 3-4 mm gen. (KG)
(2) Example of correct entry addendum: 01/01/05 ADDENDUM: 8:00 PM Follow-up phone call to pt. Pt reports “My gums feel much better now.” Rec’d that pt continue to use warm salt-water rinses for next 48 hours. Advised pt to call if symptoms flare up again. (KC)
The American Academy of Pediatric Dentistry Council on Clinical Affairs cites “poor and inadequate documentation of patient care [to be] consistently reported as a major contributing factor in unfavorable legal judgments against [dental practitioners].”5 As a result, comprehensive records are the third aspect of creating and maintaining documents that serve to protect rather than incriminate the provider.
COMPONENTS OF CHART DOCUMENTATION
In simplifying the components of complete chart documentation, we have arranged the information into 3 necessary subcategories: minimum content, additional content, and informed consent content.
At minimum, all patient files must include a representation of the logical sequence of events that occurred during the patient visit. It is crucial that a provider demonstrate that he or she reviewed a patient’s medical and dental history prior to rendering any services. At this point, subjective patient concerns or complaints should be noted (refer to the section regarding the use of quotation marks above). Because diagnostic exams or tests (including dental x-rays, oral cancer screenings, and periodontal charting) likely will be ordered, a thorough documentation of these events and findings must be made as well.
Next, the provider’s objective assessment and recommended treatment plan should be noted. Finally, case notes are to include the actual treatment performed, along with any drugs dispensed, prescribed, or administered. A final component of minimum content includes all consultative reports performed by specialists and copies of all other providers’ records when they are used to make current treatment decisions. We recommend that each provider review and familiarize himself or herself with the applicable, individual state laws for more information regarding specific minimum content requirements. (Please note a case in point: some states will mandate the inclusion of billing records into a patient file.)
Additionally, patient case notes should include a complete log of any telephone conversations held with the patient and all telephone calls to and from the patient’s physician or other dental provider(s). Letters from a patient’s medical doctor or other dental specialist(s) are part of the comprehensive treatment record and must be retained. Further, it is highly recommended that a dental office integrate into a patient’s chart a chronicle of all cancelled and broken appointments, including late arrivals and efforts on behalf of the office to reschedule the patient’s appointment. Should the need arise, such as during litigation, keeping a journal of these instances will assist a provider in establishing a pattern of patient noncompliance or inconsistency with the recommended treatment(s) or professional instructions.
The final component of holding comprehensive, protective records in your dental office involves the concept of legal, informed consent. Demonstrating that informed consent has been achieved is paramount to the concept of you are what you write. Informed consent provides the legal protection that is necessary to close a case even before a provider can be processed or disciplined through a state board of dentistry following a patient complaint. Therefore, while informed consent is the third component, it is no less critical than the others in order to achieve necessary, thorough patient documentation.
Generally, informed consent is attained when a patient is notified and understands his or her condition, the advantages and disadvantages of the recommended treatment, risks of nontreatment, and alternatives to recommended treatment. For many routine procedures, consent may be obtained through a signed general statement the pa-tient completes, often as found on a patient history form or treatment plan. Thorough documentation of informed consent should occur for more specific procedures or treatments, however, by using a separate, signed form. It is necessary to illustrate that providers have given the patient enough evidence to allow him or her to make a decision about whether to undergo the procedure as well as enough information about potential complications of the procedure. Therefore, informed consent components should be delineated, initialed by both provider and patient, reviewed, and signed. Patients acting against or declining recommended diagnostics or treatment must be noted in the chart, and, when possible, the patient should sign such an entry. Note the example below, as cited by Brown3 in her article “Board of Dentistry Violations: What Dentists Need to Know”:
“Dr. Miller performs a crown preparation on Mr. Jones, who doesn’t practice good oral hygiene. Dr. Miller notes Mr. Jones’ poor oral hygiene in his file. Before cementing the crown, Dr. Miller takes [BWXs] because he is unsure whether the margins are closed interproximally…6 months later, [Mr. Jones] moves to a new city, and goes to a new dentist… [who] takes x-rays and discovers there are gross open margins around the crown... Mr. Jones is angry and reports Dr. Miller to the BOD.
When the BOD receives copies of Dr. Miller’s notes, they decide no violation has occurred. The case is closed before it ever reaches the Probable Cause Panel. Why?”3
As indicated, when a patient either declines or acts against professional recommendations, it is possible that either the patient became angry with the dentist or a subsequent dentist might cause the patient to believe that he or she has been cheated. “Either way, accurate documentation of the patient’s poor oral hygiene habits, along with x-rays and adequate notes justifying procedure and billing codes, are a solid defense system... [without good notes and x-rays in this case], Dr. Miller could have been found guilty of a practice below the standard of care violation.”3
All dental offices that have or are interested in implementing a consistent system for record keeping will likely also have curiosity at this point about who may actually own the dental records that have been created and how must (or may) the documents be shared, retained, or released in compliance with the law. The simple answer is that individual state laws and federal HIPAA acts will regulate much of these particular aspects of medical information. For instance, Florida mandates that the practice retain an original patient chart for a minimum of 5 years following the date of the last patient contact, but other states may require an even greater time period. In terms of records release, record copies may be provided to the patient, as the practice employer, not provider or patient, is the actual legal owner of the dental records. Additionally, “the patient must receive the dental records no more than 30 days from the date he or she requests them [when the request is in writing]. This means dentists must allow sufficient mailing time when sending patients their records… [and] it is illegal to withhold a patient’s dental records when the patient, or his or her legal counsel, has requested them—even if the patient has a balance.”3
Further, providers should check with their individual state rules when selling or closing a practice in order to release or preserve the medical files in accordance with their individual local documentation laws. Owners of dental practices often may additionally wish to hold onto patient records beyond the point of possible financial audit (which is likely to be a time period greater than that required for legal compliance).
It is interesting at this point to note the issue of statute of limitations not only on malpractice suits but also on abuse cases. In the healthcare industry, be mindful of the fact that a minor is able to proceed with a complaint or a suit of abuse against a medical provider once the minor has become an adult. In other words, a recently turned 18-year-old patient may wish to pursue a complaint stemming from an incident when he or she was just 10 years old; this case in point actually may serve to extend the statute of limitations of usual and customary patient suits.
In our rapidly evolving healthcare industry and amidst the scrutiny of the information age, we dental professionals must be aware of today’s atmosphere of increasing patient complaints, disciplinary actions, and third-party lawsuits in which we operate. It is of the utmost importance that all dental practitioners take responsibility for creating and maintaining our patients’ medical records in a way that protects our practices and ourselves from this societal trend. Our missions and delivery of a high standard of care must be (and can only be) adequately, consistently, and completely reflected and supported by those documented chart notes in which we take part daily. When a malpractice claim arises and one’s records shall be the first piece of evidence that is reviewed, the proof certainly will be in the pudding.
Make your records work for you. What is written or not written could be your best friend or worst enemy! You truly are what you write.
1. Glascoe D. Prevention vs. prosecution – liability issues in dental practice. Presented at: RDH Under One Roof; July 21-23, 2005; Chicago, Ill.
2. The Florida Department of Health Web site. Available at http://www.doh.state.fl. us/mqa/dentistry/dn_minutes.html. Accessed: November 7, 2005.
3. Brown A. Board of dentistry violations: what dentists need to know. Today’s FDA. 2005; 24-27.
4. Bramley S. Medical records and the law. BJU Int. 2000;86:286-290.
5. American Academy of Pediatric Dentistry. Clinical guideline on record-keeping. Pediatr Dent. 2004;26:134-139.
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