Best Practices To Ensure Accurate Dental Recordkeeping

Although providing excellent service is rightfully the top priority for most dental practices, ensuring accurate, detailed dental recordkeeping is critical to quality patient care and the business’s success. Read on to learn the best practices for keeping patient records and the significance of accurate information.

Dental Intelligence


February 15, 2023

In the not-so-distant past, keeping clinical records often involved file cabinets full of folders containing patient paperwork, which made maintaining accurate, up-to-date information somewhat challenging. These days, most dental professionals have transitioned into the digital world, using electronic records instead of physical ones to streamline the process of documenting patient histories. 

Electronic patient records have simplified the recordkeeping process by introducing an unprecedented level of convenience when filing and storing sensitive data. This technology allows dental professionals to organize files with ease while ensuring accuracy and confidentiality. You can keep patient intake forms, treatment overviews, and digital images in the same place. 

With the Dental Intelligence Patient Portal and Digital Forms, you can easily collect patient information. These tools allow individuals to update their records anytime, securing the latest and most accurate information for your practice and empowering your patients to participate in their care.

Ensure a Higher Standard of Care

While accurate dental recordkeeping can benefit your practice in several ways, it can also ensure a higher standard of care for your patients. By including relevant and detailed information about a patient’s visits, past procedures, and current concerns, you, as a dentist, can make more informed decisions about their care.

Likewise, if a patient were to move and find a new dentist, you could easily send their electronic health record to a practice of their choosing. Sharing that updated information with the new provider ensures proper care and mitigates any possibility of confusion about past procedures.

For best practices, remember that the dental professional responsible for a patient’s treatment must be the one to document it and digitally sign or initial the record. Additionally, regardless of which team member provided care, you, as the dentist, are ultimately responsible for ensuring that all the entered information is accurate and current.

Generally, an electronic health record may include the following:

How Accurate Records Can Protect Your Practice

Integrity is essential for all healthcare professionals, and you must take accountability for mistakes. However, it’s also important for you to have a protocol in place in the event of a lawsuit or legal complication. Accurate dental recordkeeping can serve as security for your practice.

As the dentist or leading physician, you have the legal responsibility to ensure accuracy and privacy regarding patient records. Still, it’s critical for the sake of your business that all team members receive adequate recordkeeping training. This process should involve learning your practice’s documentation structure and federal and state regulations regarding patient health files.

Should your practice face a lawsuit for malpractice or otherwise, the accuracy of your dental records may influence the course of the case. You and your team must ensure detailed, up-to-date information to protect your business. Poorly kept records containing inconsistencies, incomplete documentation, or notes irrelevant to treatment may not be useful in addressing claims.

Also, understand that if a patient files a lawsuit, you will be legally obligated to share any information in their files. With this in mind, remember to keep all notes relevant to the treatment and avoid including personal comments that may compromise your credibility in the future. Keep it strictly professional.

The Importance of Performing Regular Audits

Regularly auditing your patient files is a simple way to prevent miscommunication and confusion. While your dental recordkeeping practices should prioritize inputting accurate information in the first place, you can avoid complications by routinely checking patient records.

If you plan to make any changes to recordkeeping, arrange a meeting to address those changes with staff. Consider providing a write-up of your changes so each team member can reference the new format moving forward.

Keep Better Records With Dental Intelligence

Dental Intelligence strives to help dental professionals take the guesswork out of dental recordkeeping and ensure quality patient care. Check out our informative blog to learn about improving patient experience and how to avoid dental HIPAA violations. Dental Intelligence is here to help you intelligently shape the future of your practice. Schedule a demo today!

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