Guest post by Dawn Christodoulou, President/Owner of XLDent
Whether you’re just getting started or a seasoned vet, every dentist has heard the phrase “If it’s not in the chart, it didn’t happen.” And, even though we’ve all heard it before, many dentists continue to repeat the bad habits of their predecessors, leaving themselves at risk for malpractice lawsuits and fraud.
The Dental Chart
In order for the dental chart, or electronic dental record, to be defensible in a court of law, it needs to provide a consistent and detailed account of events.
While most practices are good about obtaining health history information at the time of a patient’s initial visit, many fail to maintain consistency when it comes to updating information. With a lot of dentists counting on hygienists and assistants to update health history information, it’s easy to get lazy with your review of this information. Make it a habit to review the information in your electronic dental record prior to each patient encounter and document this in your clinical progress note. The recent addition of the Medical Tab in the XLDent chart helps clinicians view and update medical conditions and medications easily.
Failure to document a definitive diagnosis is a common weakness to the electronic dental record in many practices. The clinical progress note should reflect your diagnosis and the findings that led to your diagnosis. Supporting items, like radiographs and treatment plans, will also help strengthen and validate your progress note. Your documentation must reflect the treatment options that were recommended and alternatives that were discussed with the patient.
Prior to treatment, the dentist bears the responsibility of obtaining informed consent from the patient to perform the procedures that were diagnosed. For most, the process to obtain consent involves a conversation with the patient that results in patient understanding and acceptance of the treatment that will be provided. When it comes to malpractice claims, lack of consent is frequently cited. The clinical progress note should reference the process used to obtain consent and that the patient consented to treatment provided. For riskier procedures, consider obtaining consent in writing to help support your clinical note. One method is clinical consent forms that are signed on the tablet pc when using XLDent’s Ink Forms.
Even in 2017, many prescribers will be the victim of prescription theft or tampering. Sending prescriptions to the pharmacy electronically offers greater protection for the prescriber, reducing the risk of fraud. Additionally, ePrescribing software offers safety measures for the patient.
We hope these recommendations will help you minimize the risk of fraud or error in your clinical settings.
To connect with someone from XLDent, please call 800-328-2925 or email firstname.lastname@example.org.
Dawn Christodoulou is the President/Owner of XLDent. She has more than 25 years of experience computerizing dental offices and helping both new and established practices streamline electronic workflows for increased efficiency, improve patient engagement, and achieve maximum profitability. Dawn is also a member of ADA SCDI Working Groups 11.1 Standard Clinical Architecture and 11.9 Core Reference Data Set.