Are Your Dental Charts Working Against You? By: Jeffrey J. Tonner, J.D.

When the time comes, and it will happen, your best defense or worst nightmare will be the dental record. With proper documentation, a claim either will not be filed at all or can be dismissed with minimal involvement. The overriding concern is balancing your valuable clinical time against the tedium of excessive record keeping. While no dentist ever got rich charting, some practitioners come to regret recording only minimal information.

Defending hundreds of dentists, I have discovered a major record keeping flaw. Many practitioners record only adverse findings. For example, in an initial patient examination a clinician analyzes numerous areas. These assessments, however, often are recorded using a single acronym “CDE” [Comprehensive Dental Exam]. When pressed to prove that, say, an oral cancer screen or periodontal screening was performed, the dentist must “extrapolate from the negative.” In other words, the test was performed and found to be within normal limits; otherwise, it would have been noted. While this methodology worked years ago, today’s jurors and fact finders are more demanding. If it is not written in the record it didn’t happen. Your dental chart can become a powerful ally, but only if it cues a response for necessary information.

Returning to the initial examination, ten clinical areas ideally should be addressed. You could train yourself or the staff to record each item in the progress notes, or use a form that prompts an answer. In the illustrated Initial Oral Examination sheet, each treatment category is listed with options. By circling or checking the appropriate information, your record is complete in a matter of seconds.

Here are some additional areas where charts can enhance your record keeping:

The Health History can ask patients:

• To inform the staff of any changes in their medical or dental conditions since the last office visit (you should inquire too)

• The name of their previous dentist (a future information source, if needed)

• Whether they currently are in pain

• If they ever had problems with other dental treatment or practitioners (insight into whether you wish to accept them as patients or terminate)

• To list their current over-the-counter drugs (medically conservative; new age; hypochondriacal)

The Clinical Exam and Treatment Plan sheet can remind the staff to include the:

• Existing clinical condition (restorations, root canal treatments, missing teeth and crowns/bridges)

• Diagnoses/pathology to support any proposed treatment (by far, the most missed element in charting!)

• Treatment options

• Difference between immediate treatment needs and future services (discussed below)

The Consent Form for Immediate Dentures can:

• List the provisionals placed now and the permanent dentures to be delivered in the future (often misunderstood by patients)

• Remind the patients that insurance usually covers one prosthesis or the other, but not both

• List the prices for Phase I—immediate temporary dentures, and Phase II—laboratory relines or new permanent dentures (eliminates financial controversies)

Here is simple illustration of how a good chart can help. I see many cases each year where a patient transfers from dentist A to dentist B, often because of insurance changes. Dentist B completes his initial treatment plan and lists nine modalities. The patient is suspicious and returns to dentist A or another practitioner for corroboration. Dentist A tells the patient that three of the recommendations are necessary, but the remaining six items are not. The patient then makes an “over diagnosis” complaint. In reality, dentist B commingled immediate and future treatment by failing to distinguish between the two categories. A dental form which includes columns for “IMM” [Immediate needs] and “W&W” [Wait and Watch for future needs] simultaneously cues the dentist to differentiate between the treatment types and overcomes a potential over diagnosis claim.

As you can see, all charts are not created equally. A quick review of the forms you presently use would be time well spent.

To order the Initial Oral Examination sheet, or for additional infomation, call 602-266-6060 or visit bestdentalcharts.com.

Jeff Tonner is an attorney in Phoenix, AZ. His practice encompasses defending dentists in malpractice or board actions; writing educational books, manuals and articles; and, presenting dental-legal risk management seminars. Mr. Tonner recently has published Best Dental Charts. They contain suggested entries, like those listed in this article. Samples can be viewed on his website, bestdentalcharts.com, or by contacting him at dentlaw@jefftonner.com or (602) 266-6060.