Are your Clinical Records Good, Bad or Ugly?

I audit lots and lots of dental records. I like the challenges of auditing detailed records, as I have to pay close attention to identify potential documentation and billing issues. Unfortunately (and all too often) the records I have to audit are not detailed and result in a lot of red ink on my audit reports.

Common charting that I encounter looks like this:

Exam Notes

  • ·      Comprehensive Exam
  • ·      2 bite wings
  • ·      2 PAs

Treatment Plan

  • 1.     Pulp/ SSC #A, B, D, E, F, J, K, L
  • 2.     Ext. #C,
  • 3.     Sealants #S, T

Treatment Notes

  • ·      Completed planned TX
  • ·      Prescription amox. and T#3
  • ·      NV: 6 mo. recall


Let’s first look at what is good with this record…..

(insert crickets chirping here…)

Now lets see how this record is awful!

(In case you missed it, there is nothing good about this record.)

We are missing information in the oral evaluation to help us understand what the dentist examined. Notations should provide a clear snapshot of the patient’s oral health status at the time of the exam. This includes not only what the patient’s problem is, but also what the problem is not, which is indicated by documenting negative findings or the criteria that are ‘within normal limits’.

Oral evaluation records support subsequent treatments. When treatment is provided following inadequate recordkeeping of the oral evaluation payment for treatment AND the oral evaluation is identified as an overpayment, which is subject to recoupment from insurance companies and Medicaid alike. In order for dentists to righteously seek (and keep) reimbursement for dental care they need to tell the story of what happened with the patient, what they observed, what they recommended, why they recommended it, that they provided the billed treatments and it needs to be appropriate and medically (dentally) necessary.

If we take the above record at face value the information leaves readers with a lot of questions. For the purpose of this illustration we will assume the patient’s demographic information (identifiers and insurance) is clearly indicated elsewhere in the record.

Some of my questions include:

  1. Why did the patient present for oral evaluation?
  2. Did the dentist review the patient’s medical history?
  3. Did the dentist review the patient’s dental history?
  4. What did the dentist examine or evaluate?
  5. What did the dentist observe (positive and negative findings)?
  6. How did the dentist observe or verify his (her) findings?
  7. Did the dentist order the x-rays? (note: X-rays require a dentist’s order in most jurisdictions)
  8. If so, why did the dentist order the x-rays? Were x-rays necessary? Were x-rays taken to maximize billable procedures?
  9. Did the dentist read the x-rays?
  10. Did the information for the treatment plan stem from interpretation of the x-rays?
  11. How and why were any of the treatments appropriate and necessary (based on what information)?
  12. What was the dentist’s diagnosis(es)?
  13.  …..

There are 11 more major issues with this record! Do you know what they are?

These are all questions that should be answered for every patient, every visit (as indicated by the situation). I know I’m crazy, but can you see how answering these questions in your clinical charting can help present issues related to malpractice or fraud?

If your clinical documentation is a direct reflection of the care you provide what do your records say about you?

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See you on the other side!