Virginia Board of Dentistry

1
Virginia Board of Dentistry

• RECORDKEEPING -
• BEYOND THE REGULATORY REQUIREMENT
• Roanoke Valley Dental Society
• November 6, 2007

2

• Recordkeeping is the foundation for good patient
  care and good communications about your practice.
  

3

• Good records support billing practices and
  demonstrate your knowledge of
• your patient,
• the practice of dentistry and
• the laws and regulations governing that practice.

4

• Dentistry means the evaluation, diagnosis,
  prevention, and treatment, through surgical,
  non-surgical or related procedures, of diseases,
  disorders, and conditions of the oral cavity and
  the maxillofacial, adjacent and associated
  structures and their impact on the human body.

5

• A complete record will address every aspect of
  the practice of dentistry
• Evaluation
• Diagnosis
• Prevention
• Treatment
• Or explain why it doesnt

6
What is a record?

• Is it the file you have identified as
  belonging to the patient and only what you put in
  that file?
• Is it each piece of paper or document you
  create or collect on the patient?

7
Recordkeeping Requirements the minimum standard

• Patients name and date of treatment
• Updated health history
• Diagnosis and treatment rendered

8

• 4. List of drugs prescribed, administered,
  dispensed and the quantity
• 5. Radiographs
• 6. Patient financial records
• 7. Name of dentist and dental hygienist providing
  service

9

• 8. Laboratory work orders
• Name and address of the lab
• Patients name or initials or
• ID
• Date the order was written
• Description of work, including diagrams if
  needed

10

• the type and quality of materials to be used
• Signature and address of the dentist
• Records must be kept for not less than 3 years
  following the most recent date of service for the
  Board.

11

• An incomplete record undermines care and
  communications.
• Consider this example of incomplete treatment
  notes

12

• 18 noted in the TOOTH column
• No entry in SURFACE column
• No entry in SHADE column
• No entry in AN column

13

• Entry in TREATMENT column
• All Bond II Amalgam
• Core LTP Fair to poor.
• Incomplete Endo.
• Billing statement noted CORP02950 Core
  Buildup, Inc. Pins(18)

14

• What do you know?
• What do you want to know?
• What do you think the complaint was?

15

• The complaint was that the dentist billed for a
  core build up on 18 when he only placed an
  amalgam filling in a hole in a crown

16

• What the record didnt include was
• who treated the patient
• a diagnosis
• medical history
• an adequate description of the treatment rendered
• x-rays

17

• What do you think should have been the outcome
  of the complaint?

18

• A complete patient record
• 1. Patient identified on each
  document
• 2. Reason for visit
• Review medical/dental
• history
• 4. Patients chief complaint
• 5. Symptoms

19

• 6. Visual findings
• 7. Diagnostic records brought,
  needed or taken
• 8. X-Rays, Digital Images,
  Pictures
• 9. Dentists examination findings
• 10. Dentists diagnosis
• 11. Recommended treatment

20
12. Treatment choices discussed 13. Pt consent
for treatment 14. Treatment rendered 15. Drugs
administered, dispensed,
prescribed 16. Name of dentist, dental
hygienist and assistant who provided
service
21

• 17. Items given to patient
  18. Laboratory work orders
• 19. Financial records

22

• Remember, if it is not written down it did not
  happen.
• Consider this example of a complete treatment
  note

23

• Pt presented for consult re dental implants
• Pt reports having pain, odor and not able to
  chew on 30, has RC/crown

24

• 30 presents with abcess, bone loss, mobility,
  pocketing, bleeding upon probing, rct, porcelain
  fused to metal crown

25

• TX options
• Extract 30/graft bone/implant
• Extract 30/graft bone/fixed bridge 29-31/implants

26

• Alternatives, fees, estimated insurance and
  complications were discussed.
• Consent obtained

27

• The record included
• Medical history
• Xrays and photos
• Detailed notes regarding the extraction and bone
  grafting
• Drugs administered

28

• Note of home care instructions and products given
  to pt
• Meds dispensed and prescribed
• Appt to check tx
• Charges and billing transactions

29

• The record did not become an issue in this
  complaint which was about what the pt agreed to
  and the actual cost vs the estimate.

30
About those records

• x-rays should be of diagnostic quality and you
  are required to keep them
• Can be stored electronically
• paper copies are not required if the record is
  unalterable

31

• You own the record but must provide copies
• You must provide itemized billing statements when
  requested

32

• You must give notice by mail and in a newspaper
  before you transfer records when closing, selling
  or relocating to current patients

33

• Confidentiality must be addressed when disposing
  of records as well as all other times

34
Board of Dentistry WEB Page
www.dhp.virginia.gov/dentistry
Statutes Bulletins
Regulations Announcements
Forms License Look-up
Calendar Guidance Documents
Recent Case Decisions
35
Board of Dentistry

• 9960 Mayland Drive, Suite 300
• Richmond, VA 23233-1463
• Phone [phone]
• Fax [phone]
• Complaints [phone]
• Email denbd_at_dhp.virginia.gov