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Risk Management and Documentation in Dentistry

Edited 2021

Risk Management isn’t something most clinicians think about as they walk through the back door of their Dental Practice to start their busy day. It does, however, strike fear in the hearts of any Dental Professional when the Board or a malpractice attorney demands we turn over a chart. According to https://www.dentaleconomics.com/articles/print/volume-90/issue-11/features/anatomy-of-a-lawsuit.html, nine out of ten dentists will be sued at some time during their career. 

The information contained herein comes from mishaps early on in my days of private practice and through years of working in various venues. This experience has afforded me the opportunity to review the documentation of numerous Dental Professionals and realize the need for continued education as a vital part of all dental practices.

This course is designed to help the dental professional develop sound habits in their fast-paced dental practice that brings peace of mind regarding documentation of patient visits, phone calls and all interactions. In order to thoroughly record the patient visit, we want to be able to systematically report all relevant information.

The S.O.A.P. method of documentation (to include PARQ: procedure, alternatives, risks of doing and not doing recommended treatment and questions), is an organized and easy to follow format. It works to ensure the details of the visit are recorded as they occurred and to reduce the risk of disciplinary action by the board or a malpractice claim.

My Story: Why did I become so passionate about Risk Management and Documentation?

My first or second year out of Dental School I received a Board complaint and although it was determined here was no credence to the complaint, the Minnesota Board has the jurisdiction to reprimand anything that can be determined as inappropriate in the entire chart. They saw documentation that wasn’t done correctly, and I was reprimanded to take a course on Risk Management.

I later recall an article written in the Minnesota Board of Dentistry Newsletter about how 90% of complaints they received could have been avoided had the documentation supported the patient’s care.  My response was: Dental Students pay thousands of dollars (I paid tens of thousands, today it’s hundreds of thousands!) for my degree; whose fault is that?

For this reason, you may find I’m “over the top” in my delivery of this course. Although I’ve not had any issues with the powers that be since Minnesota, I’ve more than once had a patient claim something wasn’t said or someone “never said that.” I’ve been able to read the documentation to the patient and it has shut down all issues immediately. For that reason alone, I’ve adopted these habits to ensure I sleep well at night.

I. Purpose

A. To Deter Risk

  • When charts are documented correctly, and a patient is considering malpractice, lawyers will automatically tell individuals considering a lawsuit, they have no claim.
  • Although good documentation doesn’t eliminate the possibility of a complaint or lawsuit, it goes a long way to deter these problems.

B. Save Time and Decrease Stress

  • When charts are documented correctly, it’s easy for the Insurance Coordinator to properly document claims for easier, faster payment with less time resubmitting and/or appealing claims.

C.     Stop Accusations in their tracks

  • I have had patients come back following the presentation of their treatment plan or after completing treatment claiming we didn’t tell them some portion of the PARQ (to be explained later). When you can read the documentation back to them word for word, they have nowhere to go with their complaint.
  • Treatment Plans should be signed and dated and should state a reminder that they have been presented with a plan, alternatives to that plan, all the risks and benefits (including the risk of doing nothing) and their questions have been answered.

II. What’s needed in a chart whether it’s a paper chart or electronic records to include a back-up.

A.    HIPPA

B.     IC’s; although we have heard that informed consents do not hold up in a court of law, I’d prefer having them to not.

C.     Medical History-updated in full every two years and updated with changes at every appointment: signed and dated and “RHHx and [found no changes] or [documented changes] per verbal with patient” clearly documented.

D.    I find that most, if not all, patients don’t think there’s any relationship between their medical history and their dental treatment. I prefer a prelude or a forward in the medical history stating the importance of knowing ALL medical issues and medications.

E.     Contact information to include primary medical provider and emergency contacts

F.      Photo

III. Documentation: SOAP with addition of PARQ (time and initials of who seated the patient)

A.    The S Stands for SUBJECTIVE: This area should include

  • If I am seeing a minor, I like to document “11-year-old male presents with mother”. I do this because I want to be sure a minor has been brought to their appointment with a legal guardian. If brought by anyone other than a parent, a consent for this individual to bring this child for dental treatment may be required (depending on the state in which you practice). Personally, regardless of the state, I want consent from a legal guardian prior to treatment and a copy of their ID.
  • BP/HR; should be repeated if the patient presents with high BP and documented as 1) and 2); There should be a point whereby dangerously high BP would mean denying treatment and referral to the primary medical provider
  • CC: chief complaint in the patient’s words in quotes
  • RHHx: read meds out loud to determine correctness
  • Anything the patient asks in terms of questions
  • If there are no questions or concerns

B.     The O Stands for OBJECTIVE: In this area we should include

  • Address cc and document what you see clinically/radiographically
  • Answer questions posed in “S”
  • In a Periodic and Comprehensive Exam, I document the following
    -Address cc
    -Does occlusion contribute to cc?
    -Review HHx or RHHx
    -Caries risk
    -Acid erosion?
    -Plaque score
    -Periodontal assessment (a full six-point periodontal record)
    -OCE: oral cancer exam
    -TMJ: temporo-mandibular joint exam
    -orthodontic record of minors

C.     The A Stands for ASSESSMENT: This is your Assessment or your Diagnosis. In this area we include what you’re planning based on cc and objective observation
       -indicates a need for RCTx
       -non-restorable and indicated for extraction
       -Symptomatic Apical Periodontitis/Irreversible Pulpitis
       -Once you determine what needs to be done, the next step is PARQ. Explain the Procedure, give all Alternatives, explain all Risks and answer all Questions, then document: PARQ.

D. Stands for PLAN or PROCEDURE

  • Anesthetic and where applied (to include topical)
  • What’s used for isolation (cotton rolls, rubber dam)
  • Caries indicator
  • Etch (%), bond (brand), flowable/packable (brand), adj. finish, polish
  • Retraction cord w/ hemostatic agent (document ‘retrieved’ when removed)
  • Oral surgery procedure
    -releasing incisions
    -release soft tissue
    -circumferential bone removal
    -mesial purchase point
    -elevate/forceps extraction
    -etc., etc.
  • NV: ALWAYS document Next Visit (and if the next visit appointment is not made by the patient document: Patient Declined NV)

E. Rules that apply: Although electronic records are the norm today, there are still some clinics that utilize paper charts.

  • No spacing should be left between entries
  • When incorrect information is written and found to be incorrect, there should be a single line crossing out the incorrect information in order to be able to read it; apply the initials of person crossing out information/date.
  • No white-out
  • Addendums are dated the day they are written, and additional dates are documented for information written regarding past dental visits
  • All entries need to be initialed by the individual entering the information

F.      Administratively

  • Document cancellations made inside office policy and repeated cancellations
  • Document all failed appointments
  • Document any phone calls pertaining to patient comments regarding treatment

CONTINUED~
I also encourage anything that occurred during the appointment that made the procedure more difficult due to patient behavior. Document:

It should be noted:

-patient refused mouth pillow and had difficulty staying open

-patient uncooperative and kept bringing hand up to mouth

-patient ejected Isolite

-patient moaned t/o entire procedure

-patient struggled to sit still

-patient had heavy gag reflex

 

 

 

~
“Risk comes from not knowing what you’re doing.”
- Warren Buffet