Documentation for the Dental Practice: A Must

      Documentation by dental staff members is equally as important as documentation by the dentist. The dentist and staff entries are considered equivalent; what a staff member writes in a patients chart is regarded as representing the dentist.
All staff members should sign or initial their entries. In addition, all entries by staff members should be reviewed by the dentist, who should in turn verify the accuracy of the entries, make any necessary changes or additions, and co-sign the entry. This is particularly important for those dentists who delegate the task of writing clinical progress notes to their assistants. The data recorded by staff members under the dentist’s direction ultimately remains the dentist’s responsibility. If an entry is illegible, incomplete or incorrect, the patient may suffer consequences, and the dentist will be held liable.
     Documentation of telephone calls, conversations, and messages is another area where the dental team is of vital importance. A great deal of important information is contained in patient phone calls, most of which do not involve the dentist’s participation. The timeliness and extent of documentation of patient telephone calls are often the issue that make or break the defense of a malpractice allegation or dental board complaint. Information received on answering machines or voice mail, or from answering services, should be recorded in the patients chart in a timely fashion.
     The duplication and release of confidential patient information is yet another area in which dental team members must practice good risk management. All team members must understand that, absent a court order, patient information is not to be released to anyone without the patient’s expressed written consent. This prohibition includes releasing records to spouses, parents of adult children, children of aged parents, siblings, work associates, and insurance companies.