Patient dental records are critical in documenting a patient’s care and treatment. The information contained in patient charts should be maintained in an organized, standardized fashion with clear, complete entries. Dental records must be maintained on a concurrent basis immediately after care is provided, results are obtained and reviewed, or communication with the patient is done either in person or via telephone.
The record should accurately reflect results of examinations; recommendations for treatment; actual procedures, treatments and results; and complications or adverse outcomes.
Record maintenance is an important component of a risk management program and contributes to patient safety as well. Organization and management of dental records should be done in compliance with federal, state and professional standards. If a patient requests a copy of their records, the records must be provided to the patient in a timely manner. The patient should receive a copy of their records and the practice should retain the original patient’s records.
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