Perhaps you've heard the adage, "If it wasn't documented, it wasn't done." 

It's a sage piece of advice given by practice management gurus like Dr. Leslie Pasco and renowned dental practice management consultant, Barry Levin. But what exactly does documentation encompass? What should be documented? Is documentation primarily to protect yourself from lawsuits? 

The answers might surprise you. 

First of all, although great documentation and good notes can indeed serve as the first line of protection against litigation for doctors, nurses, hygienists, and dentists, they serve a much wider purpose than that, and if they're not done correctly, consistently, and professionally, poor notes and documentation can even prove detrimental to a practice. 

Here are a few of our favorite tips surrounding good notes and documentation that will help your 2019 dental practice get off to a smooth start: 

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Documenting policies and expectations sets everyone up for success.


First Document Policies and Expectations

Let's discuss the side of documentation that is least talked about in dental practices: systems and policies documentation. Valina Axelgard, dental business coach says, "I often go into my clients' practices and ask 'What's your financial policy?', only to find that it's not written down anywhere, and if it's not written down, it's not set in stone. Documenting your financial policy, patient cancellation policies, and employee policies is absolutely essential for the success and the bottom line of a practice. In fact, if you don't know your systems well enough to be able to document them, then no one else will either and that leads to miscommunication, inconsistent practices, and room for a wide range of mistakes." She adds, "If patients and employees don't know what's expected of them, how can they be successful? Documenting systems and expectations in a clear and transparent way sets everyone around you—both your staff and your patients—up for success." 


Consent and Case Acceptance

Good notes promote continuity of care through clear communication, demonstrate quality of care delivered, and provide evidence necessary for any legal proceedings. Conversely, poor records have a negative impact on care delivery and clinical decision making. 

Unfortunately, record keeping and documentation often become a low priority for busy dentists and hygienists and staff. 

The most important thing to document when it comes to a patient is consent and case acceptance. "This includes case refusal or refusal of treatment," says Barry Levin. "While a dentist will recommend the best course of action, it remains the choice of the patient whether or not to follow the advice. If a patient does not follow the recommendations of a dentist, it is extremely important for the dentist to make a detailed note of the event in the patient's records. Record the details of the discussion with the patient about the potential benefits and risks associated with the proposed treatment. Clearly explain the reasons given by the patient for refusing treatment in the patient's file," Levin adds. 

Documenting consent, case acceptance, and case refusal ensures that you're doing exactly what the patient wants and never going out of bounds. It protects both parties and is always a win/win. 


Don't Leave Documentation Until the End of the Day

"There are cases that oftentimes require dentists and staff to go back to notes from previous visits for appropriate continuity of care. These notes can also be essential tools for communicating with insurance companies to get coverage, but too often note-taking and documentation happens after you've seen a day's worth of patients.  At this point, many important and often crucial details are lost," says Valina Axelgard.

She coaches her dental offices to form a habit of taking a moment during or after each patient visit to record case notes and details and to not procrastinate them until after the next patient or at the end of the day. She promises this will save you on more than one occasion in the long run!

Take great notes to ensure continuity and quality of care.


Stick with the Facts

As mentioned previously, although patient notes serve a wide purpose, they're often the first source of evidence and line of defense for clinicians when faced with the unfortunate event of malpractice litigation. Thus, Barry Levin says, "It is imperative that nothing in a patient record can be viewed in the wrong context. To avoid embarrassment, liability, or the need for uncomfortable explanations, keep patient records as objective as possible. This means keeping them clinical in nature." Levin adds, "Criticizing comments or witty remarks should never be included in a patient record. Any prejorative content on a patients' record will always be brought up in litigation, and will always look unprofessional on the clinician's part." 

Another Levin tip? "Keep in mind that dissatisfied patients require the highest level of care and documentation because they pose the highest risk of making a claim against the dental practice. Keep your best and most thorough notes on the patients that you might privately consider a 'squeaky wheel.'" 


Ensure Notes Are Professional and Consistent

The ADA Center for Professional Success says, "Patient records are a vital part of your practice. Among other things, they contain information about the patient's treatment plan and care that has been delivered. Dental records are especially important when submitting dental benefit claims or responding to lawsuits." 

Barry Levin, a dental practice management expert, says, "the importance of documentation cannot be overstated." Dental practices are required by law to produce and maintain adequate patient records. Failure to do so can expose the practice to significant risks and liabilities. In addition, the Health Insurance Portability and Accountability Act (HIPAA) and many other laws and regulations require the retention of records for varying periods of time.

Clear, organized, and detailed dental records are necessary to provide patients with the best care possible. Moreover, a dental practice's records may be used in a court of law in connection with the prosecution and/or defense of malpractice claims or other civil lawsuits. As a result, here are certain "best practices" that should be considered in connection with the creation, maintenance, and destruction of patient records.


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Professional, consistent, and well-organized records are key to success.


Carefully Correct Documentation Mistakes

Here's a useful tip many clinicians fail to consider: Never delete, erase, or white out entries on a patient's official document. According to Levin, "These actions can be misconstrued as evidence of improper alternation." Instead, he recommends correcting mistakes by drawing a single line through any error with a date and initial next to the mistake before writing out the correction. 


Avoid Perception of Bias by Separating Financial Records from Patient Records

Avoid mixing a patient's financial information and insurance coverage data with their patient and clinical notes. This protects the clinician from giving the incorrect impression that any bias came into play during diagnosis, evaluation, and treatment options presentation. This also protects your patients' financial information from being passed along irresponsibly or without their permission should they request that their records be transferred elsewhere. 


We hope these tips will help you develop great documentation habits for your dental practice throughout 2019 and into the future. These guidelines ensure the best care and protection for the doctor, staff, and patients. It may seem simple, but it's often the simple things that become lifesavers in tight situations. 

Stay tuned for more practice management tips throughout the year here on The Arch: The Ultradent Blog!