Maintaining your Dental Records

By Chad Perlmutter | February 11, 2015 | 3 minute read

Dental practices are required by law to produce and maintain adequate patient records. Failure to do so can expose the practice to significant risks and liabilities.

After scanning and indexing your dental records into an electronic medical record (EMR) system, it is important to maintain an organized record management plan that will cover your practice in case of a lawsuit or audit.

Here are some of the best practices to keep your digital dental records organized and your practice compliant:

10 Ways to Properly Maintain Your Dental Records

Carefully Correct Mistakes or Omissions in Patient Records

Never delete, erase, or white out entries, and do not leave blank lines or spaces with the intent of adding more information later. These actions may be construed as evidence of improper alteration. Instead, draw a single line through any error, then date and initial the entry for verification. In addition, all boxes and blanks should be completed/filled in.

Document Any Refusal of Treatment

While a dentist will recommend the best course of action, it remains the choice of the patient whether or not to follow the advice. If a patient does not follow the recommendations of a dentist, it is extremely important for the dentist to make a detailed note of the event in the patient’s records

Stick to The Facts

Because patient records become the first source of evidence in the unfortunate event of malpractice litigation, it is imperative that nothing in a patient record can be viewed in the wrong context. To avoid embarrassment, liability, or the need for uncomfortable explanations, keep patient records as objective as possible.

Separate Financial Information From Patient Records

Financial information does not belong in the dental record. Keep all financial documents in a separate folder and filing system. It is inappropriate to include insurance benefit details, payment records, or any other pecuniary information in a patient’s clinical record.

Confidentiality

confidential information should be properly identified as such and kept out of view of unauthorized parties.

Perform Document Purges

When permitted by HIPAA and other applicable laws, hard copies of confidential documents and x-rays should be shredded, preferably by a professional shredding service. Be sure to obtain a confidentiality agreement that clearly states the date and method of destruction.

Completely Delete Electronic Files

Be aware that simply deleting e-mails or electronic documents is not sufficient. When a file is “deleted,” the raw data file remains on the hard drive. Work with an information technology specialist to ensure that confidential electronic files are completely wiped clean from computer memory.

Consult the ADA website

The American Dental Association has valuable guidance on these and other issues available online at www.ada.org.