Virginia Board of Dentistry

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

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

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

4. 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. www.dhp.virginia.gov

5. A complete record will address every aspect of the practice of dentistry: • Evaluation • Diagnosis • Prevention • Treatment Or explain why it doesn’t www.dhp.virginia.gov

6. 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? www.dhp.virginia.gov

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

8. 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 www.dhp.virginia.gov

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

10. 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. www.dhp.virginia.gov

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

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

13. 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) www.dhp.virginia.gov

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

15. 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 www.dhp.virginia.gov

16. What the record didn’t include was: • who treated the patient • a diagnosis • medical history • an adequate description of the treatment rendered • x-rays www.dhp.virginia.gov

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

18. A complete patient record • 1. Patient identified on each document • 2. Reason for visit • Review medical/dental • history • 4. Patient’s chief complaint • 5. Symptoms www.dhp.virginia.gov

19. 6. Visual findings • 7. Diagnostic records brought, needed or taken • 8. X-Rays, Digital Images, Pictures • 9. Dentist’s examination findings • 10. Dentist’s diagnosis • 11. Recommended treatment www.dhp.virginia.gov

20. 12. Treatment choices discussed • 13. Pt consent for treatment • 14. Treatment rendered • 15. Drugs administered, dispensed, prescribed • 16. Name of dentist, dental hygienist and assistant who provided service www.dhp.virginia.gov

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

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

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

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

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

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

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

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

29. 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. www.dhp.virginia.gov

30. 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 www.dhp.virginia.gov

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

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

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

34. Board of Dentistry WEB Page www.dhp.virginia.gov/dentistry Statutes Bulletins Regulations Announcements Forms License Look-up Calendar Guidance Documents Recent Case Decisions www.dhp.virginia.gov

35. 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 Board of Dentistry www.dhp.virginia.gov