Spring cleaning isn’t limited to the office: Update patient records to mitigate risks

By: California Dental Association

Spring is a prime time to deep clean your practice and tie up any loose ends from the previous year. It’s also a great opportunity to review your patient records and ensure all files are accurate and current.

Below are some things to consider when revisiting patient charts. If you find something is missing, review the chart with your patient at their next visit.

Does the chart have a signed treatment plan?
Before beginning any dental treatment, you should document the clinical exam findings, diagnoses of the patient and your treatment recommendations. A treatment plan should include a complete overview of the treatment to be performed, how it will help your patient, alternatives available and alternatives selected, in addition to any part of the treatment requiring referral to a specialist.

Note patient expectations regarding cost of treatment, overall aesthetics and longevity of treatment. Should finances affect the patient’s treatment decision, the risks and consequences of delaying treatment should also be discussed and noted in the chart.

Does the chart have a signed financial agreement?
For many patients, finances will play a significant role in the treatment plan. When discussing treatment options, be sure to include the patient’s estimated dental benefits portion of payment and predicted out-of-pocket expenses while making it clear that the patient is ultimately responsible for all fees regardless of what their dental benefits cover. If a patient has concerns about paying for treatment, consider offering payment arrangements that will fit their finances rather than altering the treatment plan. 

Keep a signed copy of the financial agreement in the chart separate from the medical history. This will help avoid mixing the patient’s protected health information (PHI) with their financial information should there be a need to share financial data with a third party that should not have access to the PHI, such as a collection agency.

Is the patient’s health history form current? 
Ideally, you should review a patient’s health history at every appointment. Go over the previous health history form and update as needed. Be sure to clarify any unanswered questions and inquire as to any recent visits to another health care provider.

Inquire about pregnancies, surgeries, radiation therapy, trips to the emergency room or other hospitalizations. Review their current medications and note if they have begun, discontinued or changed any prescribed or over-the-counter medications. Have the patient sign and date the health history form and all subsequent updates.

If you are concerned about treating a patient with underlying health issues, you can obtain medical consultation with their primary care physician before proceeding. Keep the physician’s response in the patient’s file and follow their recommendations to ensure patient safety. 

Is the patient chart inactive? 
While there are no statutory requirements, The Dentists Insurance Company recommends that you keep patient charts for a minimum of 10 years after the last date the patient is seen, if not indefinitely. For patients who are minors, you should retain their chart for 10 years from their last treatment or seven years past age 18. If you decide to dispose of inactive patient charts, it is imperative that you do so in a way that is consistent with HIPPA regulations.

In one case reported to TDIC’s Risk Management Advice Line, a dentist was seeking to shred outdated patient information. He canceled his prior contract with a licensed and bonded shredding company and hired a “friend of a friend” who promised to shred the confidential records at a reduced rate.

The dentist paid the individual $200 to shred the files without having signed an associate agreement. The dentist became concerned when he did not receive a shredding confirmation. Ultimately, he realized that he might never hear from him. The dentist also understood the potential for a claim of unauthorized disclosure of PHI should these patient records be discovered intact. The Risk Management analyst suggested ways to avoid such problems in the future and recommended reporting the matter to the police for any assistance in locating the individual.

Having a complete, well-documented patient chart doesn’t just keep your practice neat and organized, it may help resolve potential patient disputes. Your treatment records are yet another tool to clearly communicate expectations with your patient and build a foundation of trust and transparency.

For more information on record keeping and to access patient forms and associate agreements, visit

TDIC’s Risk Management Advice Line at 800.733.0633 is staffed with trained analysts who can provide guidance on patient records and other questions related to a dental practice.

Reprinted from the April CDA Journal.


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