Assuming a dentist is using computerized charts in order to create the "paperless office," are there any legal concerns as to the integrity of the clinical notes in a court of law? Should there be some sort of legal signature at the end of each dated entry?
alaskadoc, Official Townie Is scanning old paper records to a CD for storage adequate legally? Or do all the charts and stuff have to be sent to the salt mines for storage, and for how long?
gregholm, Official Townie
My opinion on computer docs is that they are OK, as long as you have the feature where entries cannot be changed after a specific period of time (24/48 hours) of being entered. I believe most software packages have this irrevocable feature. With that, I feel that juries today are sophisticated enough to appreciate the paperless office. Personally, I would not have a problem defending a DDS under these conditions. Without it, I would feel very uncomfortable. The Arizona dental board is OK with it. I have defended computer record cases there, and no one raised the issue of potential altered records.
Perhaps some of the software people who lurk here can comment? Transferring old records to a CD is very acceptable. Courts around the country do so. Here, you cannot find old "original" docs. Everything has been placed on microfiche or disk.
Jeff Tonner, Official Townie
Dental Malpractice Defense Attorney
The problem with the clinical records is that some software systems do not lock them. For example, Dentrix (pre 8.0) did not do this and if anyone knew this is a court of law, I guarantee that this would be exploited. SoftDent and PracticeWorks do a good job at locking them down, but the issue is complicated again when you get into smaller, less-used software systems out there. Some lock them and some do not.
jared-brytan, Official Townie
BryTan & Associates