Proper Record Keeping and Documentation

by  Nicole Olsen, QCC
Apr 19th, 2018

Proper record keeping and documentation is not only essential for today’s dental practitioner, but is also required by law. Moreover, correct, current and accurate records directly enhance patient care by enabling the dentist to plan treatments, monitor progress, and provide essential notations. Clear and concise treatment plans, medical alerts, and patient preferences reduce mistakes and errors in the delivery of dental therapeutics.
Single line notation is rarely adequate, and pages of notes are impractical. When one adds a host of third party agencies reviewing dental records, and a more empowered dental consumer population, it is no wonder today’s dental professional is looking for “clearing house” to disseminate this vital information.

This critically important Proper Record Keeping and Documentation seminar will allow the attendee to:
· Understand the importance and need for complete records.
· Identify a comprehensive medical/dental history.
· Accurately chart an initial examination.
· Diagnose and sequence treatment plans.
· Determine what adequate radiographs are.
· Understand the role of informed consent
· Identify a “record” and who owns it.
· Become familiar with common coding errors
Proper documentation also supports efficient claim processing. Complete and accurate claims are processed faster than those that are not, reducing resubmissions that delay adjudication and increase staff frustration. Key sections of the ADA claim form, CDT codex and appropriate diagnostic narratives will be reviewed.