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Virginia Board of Dentistry

www.dhp.virginia.gov. . Recordkeeping is the foundation for good patient care and good communications about your practice. . www.dhp.virginia.gov. . Good records support billing practices and demonstrate your knowledge of :your patient, the practice of dentistry and t

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Virginia Board of Dentistry

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    1. www.dhp.virginia.gov Virginia Board of Dentistry RECORDKEEPING - BEYOND THE REGULATORY REQUIREMENT Roanoke Valley Dental Society November 6, 2007

    2. www.dhp.virginia.gov Recordkeeping is the foundation for good patient care and good communications about your practice.

    3. www.dhp.virginia.gov Good records support billing practices and demonstrate your knowledge of : your patient, the practice of dentistry and the laws and regulations governing that practice.

    4. www.dhp.virginia.gov Dentistry means the evaluation, diagnosis, prevention, and treatment, through surgical, non-surgical or related procedures, of diseases, disorders, and conditions of the oral cavity and the maxillofacial, adjacent and associated structures and their impact on the human body.

    5. www.dhp.virginia.gov A complete record will address every aspect of the practice of dentistry: Evaluation Diagnosis Prevention Treatment Or explain why it doesnt

    6. www.dhp.virginia.gov What is a record? Is it the file you have identified as belonging to the patient and only what you put in that file? Is it each piece of paper or document you create or collect on the patient?

    7. www.dhp.virginia.gov Recordkeeping Requirements: the minimum standard Patients name and date of treatment Updated health history Diagnosis and treatment rendered

    8. www.dhp.virginia.gov 4. List of drugs prescribed, administered, dispensed and the quantity 5. Radiographs 6. Patient financial records 7. Name of dentist and dental hygienist providing service

    9. www.dhp.virginia.gov 8. Laboratory work orders Name and address of the lab Patients name or initials or ID # Date the order was written Description of work, including diagrams if needed

    10. www.dhp.virginia.gov the type and quality of materials to be used Signature and address of the dentist Records must be kept for not less than 3 years following the most recent date of service for the Board.

    11. www.dhp.virginia.gov An incomplete record undermines care and communications. Consider this example of incomplete treatment notes:

    12. www.dhp.virginia.gov 18 noted in the TOOTH column No entry in SURFACE column No entry in SHADE column No entry in AN column

    13. www.dhp.virginia.gov Entry in TREATMENT column: All Bond II Amalgam Core LTP Fair to poor. Incomplete Endo. Billing statement noted CORP**02950 Core Buildup, Inc. Pins(#18)

    14. www.dhp.virginia.gov What do you know? What do you want to know? What do you think the complaint was?

    15. www.dhp.virginia.gov The complaint was that the dentist billed for a core build up on #18 when he only placed an amalgam filling in a hole in a crown

    16. www.dhp.virginia.gov What the record didnt include was: who treated the patient a diagnosis medical history an adequate description of the treatment rendered x-rays

    17. www.dhp.virginia.gov What do you think should have been the outcome of the complaint?

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    21. www.dhp.virginia.gov 17. Items given to patient 18. Laboratory work orders 19. Financial records

    22. www.dhp.virginia.gov Remember, if it is not written down it did not happen. Consider this example of a complete treatment note:

    23. www.dhp.virginia.gov Pt presented for consult re dental implants Pt reports having pain, odor and not able to chew on #30, has RC/crown

    24. www.dhp.virginia.gov #30 presents with abcess, bone loss, mobility, pocketing, bleeding upon probing, rct, porcelain fused to metal crown

    25. www.dhp.virginia.gov TX options: Extract 30/graft bone/implant Extract 30/graft bone/fixed bridge 29-31/implants

    26. www.dhp.virginia.gov Alternatives, fees, estimated insurance and complications were discussed. Consent obtained

    27. www.dhp.virginia.gov The record included: Medical history Xrays and photos Detailed notes regarding the extraction and bone grafting Drugs administered

    28. www.dhp.virginia.gov Note of home care instructions and products given to pt Meds dispensed and prescribed Appt to check tx Charges and billing transactions

    29. www.dhp.virginia.gov The record did not become an issue in this complaint which was about what the pt agreed to and the actual cost vs the estimate.

    30. www.dhp.virginia.gov About those records: x-rays should be of diagnostic quality and you are required to keep them Can be stored electronically paper copies are not required if the record is unalterable

    31. www.dhp.virginia.gov You own the record but must provide copies You must provide itemized billing statements when requested

    32. www.dhp.virginia.gov You must give notice by mail and in a newspaper before you transfer records when closing, selling or relocating to current patients

    33. www.dhp.virginia.gov Confidentiality must be addressed when disposing of records as well as all other times

    34. www.dhp.virginia.gov

    35. www.dhp.virginia.gov Board of Dentistry 9960 Mayland Drive, Suite 300 Richmond, VA 23233-1463 Phone: (804) 367-4538 Fax: (804) 527-4428 Complaints: (800) 533-1560 Email: denbd@dhp.virginia.gov

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