The Importance of Keeping and Maintaining Dental Records of Your Patients

Dental records include various types of documentation related to each patient that you see within your dental practiceImportance of Keeping Dental Records of Your Patients

The information includes illnesses, injuries, and health complications that are currently occurring, details pertaining to the clinical-based examinations that have been performed on the patient, diagnosis of past issues, comprehensive details on treatments provided, as well as a general prognosis of the patient.

Not only are these records necessary in terms of dental care, they are required for legal purposes. These purposes include both general consumerism and for insurance companies.

Fundamental for Your Dental Practice

When keeping dental records on your patient, they must be accurate and highly comprehensive. Not only does it benefit your practice, it is a highly-valued skill for you – as a practitioner. The main purpose of these records is to ensure that your practice is delivering high-quality patient care and for the intent of following up with each individual that is seen within your practice.

Additionally, these records may be utilized in forensic science, for research purposes, and to teach others in the field of dentistry. There may come instances in which the records are required for legal purposes. Examples of legal situations that may call for these documents include insurance claims and malpractice suits.

What May be Included in Dental Records

There are many types of information that may and should be included in each dental record associated with your patients.

Examples include written notes by practitioners, radiological studies, letters from medical professionals that have referred the patient, documentation that notes the prescriptions that have been provided to the patient, identification information obtained from the patient, and the medical history associated with the individual.

Due to the large amount of information that may be included in a dental record, it is imperative that there is an organized, structured manner for maintaining and accessing that information.

Best Practices for Maintaining Dental Record

As a practitioner, you must ensure that you utilize only the absolute best of practices in maintaining the dental records of your patients. The following outlines some basic techniques that will prove to be highly beneficial to your practice:

  1. Ensure that all of the information that is kept within the record is clearly and well written.
  2. When a practitioner reviews and/or enters in new information, they should provide the date and their signature or another identifying measure.
  3. You should avoid using practitioner slang or abbreviations. If read by an outsider, the information should be written in such a way that it may be understood by anyone.
  4. All entries associated with the dental record of a patient should either be clearly written in black ink or printed from a computer or mobile device.
  5. The dental record should never include any type of financial, billing, or payment information pertaining to the patient. That information should be kept in another area and handled by other administrators in your practice.

American Dental of Georgia can help in setting up and maintaining your dental records if you elect to affiliate with us. For more information, contact us today by calling: 478-721-1300

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