Poor record keeping is one of the most common problems encountered in the defense of a malpractice suit. When. the quality of, patient care is questioned, the  records supposedly reflect what was done and why. Poor
records provide plaintiff attorneys with an opportunity to claim that patient care also must have been substandard. Even though a perfect record is neither possible nor required, records should reasonably reflect the diagnosis, treatment, consent, complications, and other key
events. Adequate documentation of the diagnosis and treatment is one of the most important aspects of patient care. A well-documented chart is the cornerstone of any risk management program. If dentists do not document fundamental clinical findings supporting the diagnosis and treatment, attorneys may question the need for treatment in the first place. Some argue that if an item is not charted, it did not happen. The following eleven items
are helpful when recorded in the chart:

1. Chief complaint
2. Dental history
3. Medical history
4. Current medication
S. Allergies
6. Clinical and radiographic findings and interpretations
7. Recommended treatment and other alternatives
8. Informed consent,
9. Therapy actually instituted
10. Recommended follow-up treatment
11. Referrals to other general dentists, specialists, or
other medical practitioners
Ten frequently overlooked pieces of information
should he recorded in the chart: .
1. Prescriptions and refills dispensed to.the patient
2. Messages or other discussions related specifically to
patient care (including phone calls)
3. Consultations obtained
4. Results of laboratory tests
S. Clinical observations of progress or outcome of
6. Recommended adjunct follow-up care
7. Appointments made or recommended
8. Postoperative instructions and orders given
9. Warnings to the patient, including issues related to
lack of compliance, failure to appear for appointments,
failure to obtain or take medication,
.instructions to see other dentists or physicians, orinstructions on participation in am’ activitv that
might jeopardize the patient’s health .’
10. Missed appointments
Corrections should be made by drawing a single line
through any information to be deleted. Correct information
can be inserted above or added below, along with a
contemporaneous date. The single-line ‘deletion should
be initialed and dated. No portion of the chart should be
discarded, obliterated, erased, or altered in any fashion.
In some states it is a felony to alter records with t

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