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Dental Documentation Guidelines: What to Include in Patient Records

Accurate recordkeeping in your dental practice is crucial for ethical, personalized patient care. Explore the dental documentation guidelines to follow so you know what to include on your charts.

Dental Intelligence


March 29, 2023

Dental records outline diagnoses, treatment plans, informed consent, and other data you obtain from patients during their appointments. These documents are fundamental to the ongoing care of your patients, so they must include detailed information.

Creating templates for comprehensive dental records may seem like a tedious task to complete. However, investing time now to gather all the information to include in dental records will help you understand your patients’ clinical conditions and protect you from legal problems down the road. 

What Should a Patient’s Dental Record Include?

Your clinical records should have a section for basic patient information, including name, date of birth, occupation, and currently prescribed medication. It’s also a good idea to add a medical history section to ensure that your recommended treatments do not interfere with your patients’ pre-existing conditions.

Add any interactions you or your staff have with your patients on their dental charts. Make sure to include which doctor examines and recommends treatment to your patients. 

Always document — in detail — your conversations with your patients about the risks, benefits, and expectations of any treatment you recommend. These treatment notes should also include your discussions over the phone or via email.

Before you provide dental care, you must record evidence of informed consent on your dental records. You can obtain this evidence from signed waivers or HIPAA forms.

Add images, radiographs, and other forms of documentation showing the progress of your patients before, during, and after treatments. 

What Should You Not Include in a Patient’s Dental Record?

Keep the financial records of your patients separate from any clinical documentation you collect. Typically, this information is unnecessary for treatment, and your front desk staff should organize and file it separately.

Treatment notes are important but avoid including any negative comments or judgments. A prosecutor could request these records during a malpractice suit and use them against you. 

Don’t try to erase any information on a patient’s dental records if you need to make amendments. Your patients could view this behavior as unethical and accuse you of manipulating their documents. If changes are necessary, you can cross out information while keeping the original notes visible.

What Happens If Your Patient Asks for Records?

Your patients have a right to view their dental records at any time. Make several copies if you need to provide them to a patient or an authorized third party. 

However, don’t give out original documents, even if you need to provide information to other healthcare providers. Per dental documentation guidelines, original documents issued by you or your staff belong to your practice. 

Investing in dental chart software is a convenient way to let your patients submit and view their records whenever they please. For example, Patient Portal allows your patients to complete Digital Forms. This tool also makes it easy for you to draft and send easy-to-navigate forms over email, so your patients can complete them before their appointments.

What Other Information Should a Dentist Know About Recordkeeping?

Ensure that your entire staff understands your dental practice’s policies around recordkeeping. Maintaining consistent documents throughout the office will help you stay organized and prevent confusion among employees. Your office should also have one designated location to secure hard copies that will reduce the risk of damage or theft.

HIPAA record retention standards require you to keep and maintain dental office records for six years. However, you should store clinical documents for ten years or longer. If you create a patient chart for someone under 18, you must hold those records for no less than ten years after their 18th birthday.

Keeping records safe protects your practice from accusations of unethical care. These records will act as a primary source of evidence and provide just cause for your treatments. 

Digital Resources That Help You Manage Your Dental Practice Documents

Many dental practices do not take the time to meticulously curate their records, resulting in legal problems and reduced service quality. Avoid making the same mistake when managing your office.

At Dental Intelligence, we offer tools that help simplify accurate dental recordkeeping for dentists like you. Schedule a demo to see how our suite of digital tools can help you intelligently shape the future of your practice.

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