LEGAL PROTECTION - Documenting the Other Stuff for Your Legal Protection

My patient had missed quite a number of appointments and I was ready to dismiss him from the practice.  I didn’t want the legal risk of decalcifications, trauma from loose appliances or frankly, the poor reputation that comes from someone saying that I took three years to complete their braces.

When he didn’t show again, I decided that it was time to pull the trigger. I asked the assistant to give me the chart for review.

Even though I had remembered five or six broken appointments, I quickly discovered that we had recorded only one previous broken appointment. CRAP!  If they ever challenged my decision, I didn’t have the documentation to support it.  We had always been good about recording what happened in the chair, but now I needed to figure out a way to document all the important stuff that happens when the patient is NOT in the chair.

NON-CLINICAL CHART ENTRIES

My staff and I decided that in addition to the patient visit, the three most important times to record items in the treatment chart were:

1. Cancelled, rescheduled or missed appointments
   • To record lack of cooperation with scheduling or keeping appointments
2. Telephone calls from patients/parents
   • requesting special appointments for broken brackets or other repairs
   • or wanting to speak to the doctor
3. Telephone calls from dentists or their staff
   • To record important treatment information relayed by dental staff or a conversation with their dentist.

 CANCELLED, RESCHEDULED OR MISSED APPOINTMENTS

The front desk should record in the patient chart all cancelled or rescheduled appointments as soon as they occur.  For a voicemail cancellation that has not been rescheduled, enter “CA by message”.  If the appointment was rescheduled that day, then “CA/RS <date>” can be entered. For a telephone call during business hours that wasn’t rescheduled, “CA - mother will call” documents who called and the promise to call again.    It’s also important to record if multiple appointments were offered and declined by the patient.  For example, “CA - Declined 3/7, 3/9 & 3/14 – RS 3/21”.  This kind of entry has helped us several times when a parent blamed us for not getting them in sooner.

 Similarly, missed appointments should be entered as well.  “MA– left message to call back” or “MA- R/S <date>” will record the actions the office took to get the patient rescheduled, demonstrating your efforts to properly manage their care.

TELEPHONE CALLS FROM PATIENTS/PARENTS

            For offices with digital charts, a brief entry by the receptionist that records the “Message/Concern” and the “Advice Given/Action Taken” is all that is required. For example, “mother reports bracket off – scheduled 3/17” or “pt. has swelling/dr. to call back”.

For practices with physical charts, you can use the “Patient Documentation Form” (attached), which is then placed in the chart for the next appointment.  When they come for their regular or “Repair” appointment, the assistant & doctor can be well aware of the issue and address it immediately.  In addition, if the call is taken after hours, the on-call person can use the form to document the conversation or office visit.

            Return calls from the doctor to the family also need to be recorded in the chart. If the Patient Documentation Form (PDF) is filled out completely, you’re better prepared to answer their questions or concerns.  (My pet peeve – I despise those pink telephone slips.  Rarely do they provide me with enough information to handle the call well.  The PDF prompts the front desk to provide me with the needed info)  

TELEPHONE CALLS FROM DENTISTS OR THEIR STAFF

            When returning calls to dentists, notes can be made either in the digital chart or using the PDF (without the need to retrieve the physical chart first). If the PDF is used instead of the pink telephone call slip, a reliable assistant then can enter the notes from the conversation into the treatment record or file/scan the form into the chart.

As with calls from parents, information provided by other dental staff should be recorded in the treatment chart.  Entries like “had extractions on 3/8/18” or “needs a restoration before ortho” will inform everyone in the office, thereby reducing the possibility that important communications getting lost in a busy practice. 

CONCLUSION

Once we instituted these changes, it was so much easier to retrieve relevant information, answer questions, and understand any delays in treatment.  Also, if a family ever decided to blame us for their own failing to comply with treatment, we’d be better protected. Often, a thorough treatment record is THE deciding factor when a lawyer or the State Board comes calling.