II. The Recordkeeping Trail
What comprises a "patient record"?
Is a patient record simply comprised of the patient's examination documentation, the appointment notations and the radiographs? What about the models that were taken some years ago? Should one keep the laboratory prescription orders? If so, for how long? Are telephone conversations part of the record? What about patient records of minors? Do they have any different requirements? Does the record retention time requirement vary depending on the nature of the dispute at hand? Are there special requirements for digital records? How are patient requests for records to be addressed, and is it the same or different than when addressing requests for records from administrative governmental bodies?
Documentation of patient care is an absolute necessity, yet it is surprising how much variation there is among practicing dentists in the manner in which patient records are kept, what is included, and how long these records are retained. While dentists may vary in what they do in practice, attorneys hardly ever vary in their expectations and demands in what is to be produced during litigation.
At first glance, all dentists believe they know what should be included in a patient's chart. They strive to attain the goal of completeness; however, without routines in place, the best intentions can fall short.
Patient records are not just about the patient. They are also very much about the dentist. They are the dentist's best defense tool in any litigation.
For legal purposes, the "i's" must be dotted, and the "t's" must be crossed. Neatness, organization and legibility count. Notations need to be signed or initialed. Documentation should be contemporaneously recorded. Policies and procedures need to be in place, not only for the dentist, but also for his support staff. Office manuals should be adhered to.
Individuality is not rewarded if a critical element in recordkeeping is missed. "Clerical errors" are a poor excuse for improper and inaccurate documentation. Any competent attorney can make documentation errors a close cousin to treatment errors, sloppy documentation a twin to sloppy dental treatment, and missing or inaccurate notations equivalent to malpractice. It is all in the attorney's presentation, and it is highly effective with the ultimate decision makers.
Time taken to be precise, organized and comprehensive is time well spent. It translates to less time later defending a lawsuit.
So, how can all this be done repeatedly, efficiently and effectively?
Lillian Obucina, Inc. is a resource for dental professionals on the law, regulations, and codes of ethics in dentistry. Education, information, insight, and motivation can avoid legal and ethical problems, and eliminate much uncertainty in dental office operations and patient management.