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 aftercare 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 the 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.
For More Information on Topics Related to Record-Keeping, View These Posts:
– Documentation for the Dental Practice: A Must
– Practice Data Security Policy and Standards
Stuart J. Oberman, Esq.
Stuart J. Oberman is the founder and President of Oberman Law Firm. Mr. Oberman graduated from Urbana University and received his law degree from John Marshall Law School. Mr. Oberman has been practicing law for over 30 years, and before going into private practice, Mr. Oberman was in-house counsel for a Fortune 500 Company.
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