by Julie Kent, RDH of Dentegrity Records Assessment, LLC
Do your clinical treatment notes and financial ledger indicate a Comprehensive Oral Evaluation (D0150) was performed and billed? Be sure your tooth charting illustrates the entire oral condition as presented on the initial patient visit. Section 5.14 of the MA Dental Regulations:
Content of Patient Records at a minimum must include…
(c) 3. Intra-oral and extra-oral soft tissue examination, including charting of existing restorations and current status of patient’s hard and soft tissue
Recently, a local dentist shared with me a brief story about dental charting and the new patient. Here is a synopsis…
A new patient was seen for a comprehensive oral evaluation, radiographs and gross debridement. During the appointment she indicated she had been treated by the same dentist for nearly 20 years up until the dentist’s retirement two years ago. She presented with moderate calculus, two restorations exhibiting recurrent decay, root caries and two fractured mandibular anterior composite restorations. All findings were documented in the tooth chart. The patient was provided with a verbal treatment plan which included fine scale and restorative appointments.
Two weeks later, the dentist received a letter from the patient requesting her radiographs be sent to a new dentist, alleging the hygienist “broke the white fillings on the lower front teeth during the cleaning.”
Fortunately the dentist’s thorough documentation and complete tooth chart from the comprehensive oral evaluation illustrated the fractured restorations. This evidence halted her allegations before the accusation escalated. The dentist contacted the patient and reiterated his initial findings; in the end, she returned to his office to proceed with her restorative treatment!
The absence of documentation in the clinical treatment record can be damaging to you … where is your chapter to the patient’s story? Your documentation of the clinical presentation of the new patient is the historical perspective that no one has except you! Remember, if an external party were to request the patient’s dental record, will your documentation tell the entire story?
Julie Kent, RDH of Dentegrity Records Assessment, LLC
A service for the profession to help navigate the complexity of today’s record-keeping protocols as well as minimizing risk for the dentist and their practice. * 774-265-0167