Dental Office Chart Notes Are Legal Medical Records
Dental office chart notes are official documents. Patient chart notes record treatment performed. And patient chart notes also record office communication with the patient. These critical records support the dental administrative professional in patient communication. And provide valuable information to the entire team. Not to mention their role in dental insurance claims or liability insurance for the practice as well.
Medical records and record keeping vary from state to state in the United States. And it’s important that all dental team members are aware of the laws governing their state. However, both state and federal laws govern how these documents are handled, how long they are kept, and who has access to the records. The dental practice does own the patient chart. But patients also have the right to access to all of their complete dental records, and to ask for copies.
Electronic Chart Notes
Dental office chart notes are most often electronic at this time. However, I remember the days before we worked solely on computers in the dental practice. And have worked with practices transitioning from paper charts to electronic record keeping. It’s nice to not have to run around the office looking for a patient’s chart. However, it is much easier to make a note in the wrong patient’s chart electronically.
We must be very cautious and mindful in our chart notes. At the dental front office, we juggle many tasks at the same time. And may even have more than one patient on our mind at any given moment. We may have a patient on the phone at the same time that another patient arrives to check out. But we haven’t finished our chart note from the patient who just spoke with us about their prescription refill needs. We do well to make our complete chart notes as we finish working with each patient. And make side notes on a note pad if we need to go back to a chart later.
Dental Office Chart Notes: What’s Inside
Dental office chart notes must be meticulous. This is an official medical and legal record. So, it’s important to keep in mind that others may read every word. Correct spelling is absolutely essential. Thankfully, with electronic records, we have some help with that! And we want to keep most of our actual chart notes clinical in nature. The dental administrative team must not add opinions or non-clinical information as a chart note. Just one more reminder, legally, we are bound to our individual state legislation.
Here is a list of what is normally included in the dental office chart notes:
- patient demographics
- consents and record transfers to and out of the practice
- previous dental offices and incoming x-rays, perio charting, etc.
- dental and medical history
- diagnostic records
- progress and treatment notes
- medication, prescriptions given, refills
- patient complaints and resolutions
- conversations about proposed treatment
- radiograph review
- lab work order forms
- periocharts and notes
- molds and shades of teeth for lab work
- missed appointment notes
- patient non-compliance notes
- home care instructions
- frequency of hygiene recall visits
- pamphlets given to patients
- any cancelled and not rescheduled appointments
- all attempts to reach patient to schedule treatment
- correspondence (letters & phone calls)
- referrals to specialists
- follow ups from specialists
- dismissal letters or transfer out
- date chart inactivated
- date of patient’s death
Using Abbreviations In Patients’ Chart Notes
Dental office chart notes are quite extensive. And they definitely include a whole lot of information! So, it can be helpful to use abbreviations. But it’s best and most professional to use a list of office approved abbreviations only! And to have a set format that everyone in the office uses. If a new abbreviation is needed, add this item to a team meeting agenda. Don’t just make something up and run with it!
There are some very common abbreviations that we find in dental practice chart notes. I have made a short list for you. And you can certainly adjust as necessary and add to as needed. But be sure to keep a “key”. Every office wants to have this key or guide available for new team members that are hired. Or for any insurance or legal audit of a patient chart as well. And be sure to update your key as you add or change any abbreviations as well.
BA – broken appointment
BOP – bleeding on probing
2BWX – 2 bitewing radiographs
4BWX- 4 bitewing radiographs
CRN – crown
Ex – exam
EXT – extraction
Fl – fluoride
FMX – full mouth series of radiographs
NKDA – no known drug allergies
NSF – no significant findings
PA – periapical radiograph
panx – panoramic x-ray
P.O. – post operative
Pro, Prophy – prophylaxis
RX – prescription
TX – treatment
WNL – within normal limits
Dental Office Chart Notes By Administrative Team Members
Dental office chart notes provide the front office team with support and information. Keep in mind, that the dental front office team talks to more patients than anyone else in the practice each and every day. And all of that information is swirling around in our heads! We need clear, concise, and accurate chart notes to best care for our patients. Is our patient on a 6 month recare? And which specialist were we referring him to? We want that information at our fingertips in a few seconds! And we want to understand it too!
The dental front office team will make chart notes of conversations and communications with patients. We don’t want to necessarily include a conversation with a patient who has chosen to reschedule their hygiene or restorative appointment. Unless of course they have requested an appointment a ways out in the schedule. If their reschedule throws them off a 3 month recare rotation and puts the patient on a 6 month rotation instead, make a note of that. And note why the patient did so. Their dental hygienist can then read this note and discuss the importance of the 3 month schedule at their next hygiene visit.
Stick To The Facts!
Dental office chart notes must stick to the facts. No drama here! We are not writing a novel. But adding to a legal document. So be sure to read over what you have written in the patient’s chart. And then you will sign the chart note in the manner delegated by your practice chart note protocols.
Make a note when a document is scanned to a patient’s chart. Or when x-rays are imported from another practice or specialist. Just a simple date and a note, “scanned medical history to chart” with your signature is enough. If the medical history cannot be found, or is not legible, we want to know what happened. Or at least try to figure it out.
When a mistake happens within a chart, note it. Let’s say someone does make a note in the wrong chart. And maybe doesn’t catch that until the next day. We don’t ever want to delete a chart note. That opens up a whole new can of worms and suspicion. Simply make a note as an addendum that the wrong chart was noted. And that this is an error. Then make a note in the correct chart. And sign and date. We all make mistakes. But don’t make an innocent mistake look like possible fraud with a chart note deletion.
Dental Office Chart Notes With Conformity
Dental office chart notes must be concise, conform to an office protocol, and consistent. And everyone on the team must adhere to the protocol. Does your office have a protocol on patient chart notes and how these are managed? If not, make this your focus for the next 30 days. Write your protocol during a scheduled team meeting. Set the abbreviations you approve for usage in your practice. Discuss how you want each chart to look and represent the practice.
I’m here for you too! Should you want some additional support in bringing this all together, I’m here. And just an email away. Maybe you are not sure how to begin to write protocol for your dental practice. Or how to get the dental administrative team or any team member trained in your existing chart note protocol. Let’s chat about how I might be able to help! I look forward to talking with you.