Virginia Board of Dentistry RECORDKEEPING - BEYOND THE REGULATORY REQUIREMENT Roanoke Valley Dental Society November 6, 2007 www.dhp.virginia.gov

Recordkeeping is the foundation for good patient care and good communications about your practice. www.dhp.virginia.gov

the practice of dentistry and Good records support billing practices and demonstrate your knowledge of : your patient, the practice of dentistry and the laws and regulations governing that practice. www.dhp.virginia.gov

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. www.dhp.virginia.gov

A complete record will address every aspect of the practice of dentistry: Evaluation Diagnosis Prevention Treatment Or explain why it doesn’t www.dhp.virginia.gov

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? www.dhp.virginia.gov

Recordkeeping Requirements: the minimum standard Patient’s name and date of treatment Updated health history Diagnosis and treatment rendered www.dhp.virginia.gov

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 www.dhp.virginia.gov

8. Laboratory work orders Name and address of the lab Patient’s name or initials or ID # Date the order was written Description of work, including diagrams if needed www.dhp.virginia.gov

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. www.dhp.virginia.gov

An incomplete record undermines care and communications. Consider this example of incomplete treatment notes: www.dhp.virginia.gov

“18” noted in the TOOTH column No entry in SURFACE column No entry in SHADE column No entry in AN column www.dhp.virginia.gov

Entry in TREATMENT column: “ All Bond II Amalgam Core – LTP Fair to poor. Incomplete Endo.” Billing statement noted “CORP**02950 Core Buildup, Inc. Pins(#18) www.dhp.virginia.gov

What do you think the complaint was? What do you know? What do you want to know? What do you think the complaint was? www.dhp.virginia.gov

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 www.dhp.virginia.gov

who treated the patient a diagnosis medical history What the record didn’t include was: who treated the patient a diagnosis medical history an adequate description of the treatment rendered x-rays www.dhp.virginia.gov

What do you think should have been the outcome of the complaint? www.dhp.virginia.gov

A complete patient record 1. Patient identified on each document 2. Reason for visit Review medical/dental history 4. Patient’s chief complaint 5. Symptoms www.dhp.virginia.gov

6. Visual findings 7. Diagnostic records brought, needed or taken 8. X-Rays, Digital Images, Pictures 9. Dentist’s examination findings 10. Dentist’s diagnosis 11. Recommended treatment www.dhp.virginia.gov

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 www.dhp.virginia.gov

17. Items given to patient 18. Laboratory work orders 19. Financial records www.dhp.virginia.gov

Remember, if it is not written down – it did not happen. Consider this example of a complete treatment note: www.dhp.virginia.gov

Pt presented for consult re dental implants Pt reports having pain, odor and not able to chew on #30, has RC/crown www.dhp.virginia.gov

#30 presents with abcess, bone loss, mobility, pocketing, bleeding upon probing, rct, porcelain fused to metal crown www.dhp.virginia.gov

Extract 30/graft bone/implant TX options: Extract 30/graft bone/implant Extract 30/graft bone/fixed bridge 29-31/implants www.dhp.virginia.gov

Alternatives, fees, estimated insurance and complications were discussed. Consent obtained www.dhp.virginia.gov

Detailed notes regarding the extraction and bone grafting The record included: Medical history Xrays and photos Detailed notes regarding the extraction and bone grafting Drugs administered www.dhp.virginia.gov

Note of home care instructions and products given to pt Meds dispensed and prescribed Appt to check tx Charges and billing transactions www.dhp.virginia.gov

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. www.dhp.virginia.gov

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 www.dhp.virginia.gov

You own the record but must provide copies You must provide itemized billing statements when requested www.dhp.virginia.gov

You must give notice by mail and in a newspaper before you transfer records when closing, selling or relocating to current patients www.dhp.virginia.gov

Confidentiality must be addressed when disposing of records as well as all other times www.dhp.virginia.gov

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

9960 Mayland Drive, Suite 300 Richmond, VA 23233-1463 Board of Dentistry 9960 Mayland Drive, Suite 300 Richmond, VA 23233-1463 Phone: (804) 367-4538 Fax: (804) 527-4428 Complaints: (800) 533-1560 Email: denbd@dhp.virginia.gov www.dhp.virginia.gov