Avoiding Dental Malpractice Claims: Keeping Detailed Records

Dental Malpractice Prevention > Documentation

In this series of blogs, we’ve covered some best practices for how dentists can avoid malpractice claims, starting with peer review tactics and ensuring proper communication strategies. In this final article, we’re going to cover some approaches to ensure detailed records are kept. These serve as the paper trail (even digitally) for dentists to protect themselves in a court of law, making record keeping an important part of their day-to-day activities. More importantly, protect yourself and your business with a Dental Malpractice Insurance.

Be careful about correcting written mistakes.

Seemingly insignificant aspects of transcription can create significant problems. Never delete, erase, or white out entries, and do not leave blank lines or spaces with the intent of adding more information later. These actions may be construed as evidence of improper alteration. Instead, draw a single line through any error, then date and initial the entry for verification. In addition, all boxes and blanks should be completed/filled in, says Dentistry IQ.

Document treatment and refusal of treatment.

If you recommend a procedure be completed, but the patient declined, put that in their customer file. Note the discussion in detail and include the fact that you notified the patient about potential benefits and risks of the procedure. It’s also critical to include the reason for the patient declining the procedure. This way, if you get sued for any reason, you have documented evidence of your process.

Stick to the facts.

Patient records are the first thing to be viewed when it comes to litigation, so don’t include anything in the comments that could be misconstrued or misinterpreted. Stick to the facts and the facts only.

Keep it confidential.

Payment information should not only be separated from the patient charts, it should also be kept confidential. In addition, if you keep hard copies of patient records in the office, be sure they are shielded by blank cover sheets or folders to protect their identity and diagnoses from wandering eyes.

Be cautious about emailing patients.

Patient confidentiality can be compromised, as it is difficult to confirm the identity of the author of an e-mail, and e-mails can be misdirected to third parties. Be careful about using the “reply to all” function, and always double-check the recipients of any e-mails that contain (or solicit) confidential information. In addition, important points can be lost in translation in an e-mail. Always be clear and specific, and do not assume what the other party knows. If anything, write an e-mail as if an unrelated third party was going to read it and be able to understand it. Copies of all e-mails should be retained in the relevant chart.

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