One of the most important steps dental practice owners can take to limit their risk of malpractice lawsuits is to be proactive about record-keeping and documentation. Keeping and organizing thorough records can help you defend yourself against dental malpractice lawsuits and investigations by your state oversight agency for alleged misconduct. In addition to helping you defend against malpractice claims, good record-keeping can also help you improve the consistency and quality of patient care.
What Information Should You Include in Dental Records?
An important part of risk management involves including important information in each dental patient record. One of the most stressful experiences for a dentist could be finding out that a patient who came to your practice years ago for a single visit is now pursuing a dental malpractice claim against you.
Having accurate and complete records at the time of treatment that include the patient’s name and information could be the difference between paying hundreds of thousands of dollars in a malpractice claim and dismissing the case. A quality dental record that reflects the evaluation of the patient and their subsequent treatment should contain all of the following information:
- An accurate patient history, including the patient’s symptoms and complaints and the purpose for their visit
- The scope and nature of the examination that happened
- Documentation of any notable findings, negative or positive
- The dentist’s assessment of the patient, including an identification of any conditions that require treatment or diagnoses
Keeping Documentation of Diagnostic Images
Documenting diagnostic images is crucial. The images can help you prove that the treatment you gave to the patient was appropriate and beneficial. They can also show that the diagnosis and treatment plan you created were reasonable under the circumstances.
Dental patients may refuse treatment for a wide range of reasons, including financial reasons. If the patient refuses to have images taken or any other treatment recommendations, including going to a specialist, ensure the record includes this information. You should write down the diagnosis, the recommendation the dentist made, the underlying reason for that recommendation, and the fact that it was discussed with the patient and the patient clearly refused.
Document the Treatment
If the patient agrees to the treatment plan a dentist recommended, documentation of consent for the treatment is important. It’s also important to include details about how the treatment was performed, and the type and quality of the anesthetic administered by the dentist. The name and specific dosage of medication should be written down in the patient’s file.
If X-rays were taken, that fact should also be noted in the file. The records should be detailed enough that a dentist who isn’t familiar with the patient should be able to determine what treatment was provided and the reasons it was provided by reading the file.
Document Any Adverse Outcomes
Adverse outcomes can happen even when providing the best dental care possible. If anything unusual or adverse occurs during treatment, record keeping is especially important. The dentist should write down exactly what happened and speak to the practice manager or owner as soon as possible.
Contact an Experienced Dental Attorney Today
Effective recordkeeping and documentation can help your dental practice defend against malpractice lawsuits. The skilled dental attorneys at Mahan Law can help you review your recordkeeping and documentation processes to find areas for improvement. We will work with you to develop effective risk management strategies to avoid dental malpractice lawsuits and investigations by state agencies. Don’t hesitate to contact Mahan Law to schedule a complimentary case evaluation.
