Things Every New Graduate Should Know about Record Keeping!

Iunderstand, as a dental student and soon to be dentist, record keeping may be the very last item on your priority list. Been there, done that and lost the t-shirt.... literally. You see, I not only lost my t-shirt, but almost everything I owned, except the love and concern of my family and friends, but that’s another story for another day. I have come to appreciate the fact that it is a wise man who learns from his mistakes, but a wiser man still who learns from another’s. I was found guilty of healthstantial. OUCH!

care fraud, racketeering and structuring just as my son was graduating from dental school in the spring of 2008. I spent 19 months in

federal prison and two months in a halfway house, forfeited $200,000 as a result of the racketeering and structuring convictions and paid back the $17,899.57 I received over the course of 6 ½ years from the Medicaid program that I was not entitled.

I learned the hard way that if it’s not in your dental record:

1. It was not seen 2. It was not said 3. It was not heard 4. It didn’t need to be done 5. It wasn’t done 6. It doesn’t exist… from the legal perspective Your record can literally make the difference in a jury’s verdict, the dismissal of a malpractice claim, a review by the dental board that finds no grounds for action, or a “clean” insurance audit. I was accused of fraud, in part because my dental record did not justify the need for treatment. In fact,

I just finished another audit for a doctor who is in trouble with a regulatory agency, and the issues remain the same. “The documentation does not support the treatment provided.”

http://www.lexi.com • Review histories before each visit thereafter, even if seen two times on the same day. • The histories must be reviewed, documented and any modifications of treatment necessary as a result of the Medical condition of the patient should be noted and followed. Documented Detailed Clinical Examination

This doctor faces significant financial loss. The entity is asking for repayment for the “unjustified” services and the demand is sub-

If it’s not in your dental record, you didn’t see it, you didn’t say it, you didn’t do it, it didn’t need to be done and it doesn’t exist from a legal perspective. My plea to you is to be careful to document in such a way that there’s no question left unanswered, no service provided left to the imagination. The dental record should read like a story that has a beginning, middle and end where everything is recorded. I know, I know. There are only so many hours in a day, but

• Remember, an oral cancer screen is mandatory when reporting most examinations for reimbursement. Make note that the screening was conducted and the result. Hard and Soft Tissue Exam:
• Soft tissues: lips, gingiva, buccal mucosa, tongue palate. • Periodontal evaluation/charting for every patient (establish your office’s protocol). • Hard tissues: bone and teeth. • The record should be complete and specify what information was evaluated to determine the treatment recommended/provided. Radiographs/Photograph

ask this doctor who will most probably write a six-figure check. The time taken to document completely would have been very well spent and could have ultimately prevented this action. When you are tempted to cut corners in your recordkeeping, billing and coding systems weigh the consequences and choose wisely. Take it from me, defending yourself and your practice is priceless.

Record Normal Findings and Abnormal findings including: • Head and neck. • Soft tissues/photos. • Hard tissues/radiographs/photos. TMJ evaluation Caries Risk Assessment: CAMBRA Chief Complaint

What should the record contain? Comprehensive Medical and Dental History

• Review the history thoroughly at the first visit and update at all subsequent visits • Revisit with a more comprehensive review as needed (the more compromised the patient’s health, the more often the medical history should be reviewed. Err on the side of caution). • Do a Rx review and run a drug interaction screen. Consider using epocrates or lexacon. http://www.epocrates.com or
• Why is the patient in your office? • Establish the expectations from the patient. • If no problem is stated, record the reason for the visit. • Be aware that the chief complaint may change so note each visit.

List a Definitive Diagnosis

• Treatment Plans should address all abnormalities. • Complete documentation includes the diagnostic tools used to arrive at that definitive diagnosis. • Diagnosis should list the location and extent of the pathology. Informed Consent
• Treatment needed. • Reason for treatment recommendations. • Material treatment risks. • Benefits. • Clinically accepted alternatives. • Cost relative to treatment recommendations. Treatment Rendered
• Where was the patient referred? • Reason for the referral. • Lack of compliance. All Prescriptions Written
• Anesthesia: amounts, types, and locations. • Numbness. • Procedure. • Materials used. • Any negative outcomes.

Make the perfect transition

Making that first transition into your career is the most important decision you will ever make. For more than 30 years, ADS and its local transition specialists have helped dental graduates like you make the perfect first transition. As the nationwide leaders in practice purchases, we know the best opportunities wherever it is that you want to be. We are dedicated to your success.

Get off to the perfect start. Visit us online to find your local ADS representative.

Does stuff happen? • Inform. • Deal with additional treatment/referrals. • Refusal of any kind or request to modify treatment. Reason for Next Appointment

untoward effects from the medications. • (Check with your state regarding the Rx. database). All Phone Conversations

• Conversations with business staff. • Conversations with clinical staff. • Conversation with the doctor. • Conversation with the referring doctor about that patient. Cancelled/Missed Appointments
• Treatment should be sequenced to address the condition of greatest concern. • Address the chief complaint. • Address the reason for the sequence. • Get agreement from the patient for the next appointment. Note Any Referrals
• Compliance can be very important to outcomes. Remember! Make your notations at the time of the visit, phone call, conversation

If a correction or addition is needed, note when and why the correction was made.

List prescriptions separately and include number and strengths. • Indicate what the prescription is to treat. • Inform the patient of any possible side effects. • What to do if they experience any

Subjective comments about the patient are not to be recorded in the treatment record!

Be very careful with your choice of words.

See “Record Keeping” on page 35

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