Effective Management of Patient Records in Dental Practices

DA117Practice Management Records Management

Misfiling • The most common cause of missing patient records • Dental assistants help out the front desk by pulling and filing charts, but must know proper alphabetical filing techniques

Patient charts contain • Medical and dental histories • Exam and treatment records

Correspondence related to patient care • Prescription and lab orders • Radiographs

Patient charts are legal documents and involve confidentiality issues. • Contents are owned by the dentist but patient must be allowed access to their own record.

Transfer of Records • Originals are always kept by the dentist and copies are sent out. • Original xrays are kept by the office and duplicates are sent out

Reasons for Transfer • Change of dentist • Relocation • Dentist to consult with another dentist • Referral to a specialist

Must have written consent from patient to transfer records

Transfer records without written consent • Court order – Child abuse, elder abuse • Domestic violence • Military • Insurance fraud • Workman’s compensation

Alphabetizing = Indexing Units • Unit I Surname • Unit II Given Name • Unit III Middle name • Unit IV Senority, degree, titles • Common Errors • Macneal McNeil • St. John Saint John • Hyphenated last names. i.e. – Brown-Smith

Protection • Originals must not be taken out of the office • When not in use, put in proper place • Return to filing system at the end of the day • Pack records tightly together, slows fire damage • Close and lock all filing cabinets • Back up computerized records

Categories of Records • Vital – Can not be replaced • Patient’s clinical record • Deed to office

Important – Valuable but not vital • Accounts payable receivable records • Cancelled checks • Inventory and payroll records

Useful – Different in each office • Employment applications • Expired insurance policies • Petty cash vouchers

Unimportant – • Notes • Memos

Types of Records • Clinical – • Information regarding patient treatment • Registration form • Health history – no blanks • Consultation/referral reports • Consent forms

Financial • End of day reports • End of month reports • Payroll reports • Paid bills

Life Cycle of Records • CREATION – Begins with patient registration and health form – Is patient permanent or emergency only?

DISTRIBUTION – Chart given to doctor for diagnosis

USE – Evaluation of data – Diagnose, treat or refer?

MAINTENANCE – Should information be saved? • DISPOSITION – Chart destroyed or stored permanently

Effective Management of Patient Records in Dental Practices

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