Chart Documentation: How will you fare if HIPAA comes knocking?

HIPAA audits are on the rise, and it is more important than ever that dental practices make sure their t's are crossed and their i's are dotted when it comes to patient records. Anything less and you are subjecting yourself, your team and your entire practice to unnecessary - and potentially very costly - consequences.

How is your practice doing?

As a practice management consultant, my responsibility is to help doctors recognize, and then correct, any number of common problems relating to patient records and chart documentation. Please take the time to read on, and find out if any of these sound familiar to you. The list is not exhaustive, but does represent a number of the most common risk-related issues I see on a regular basis.

PROBLEM: Your front desk or admin person does not have a dental background, and therefore finds it hard to read or understand your notes.

SOLUTION: Proper training for your admin staff is vital, as is your responsibility to make sure your notes are complete, readable and understandable.

PROBLEM: Your notes are vague and/or incomplete.

SOLUTION: As above, plus, remember, legally you must have a treatment plan for every tooth and every patient. The treatment plan must cover what you are doing, and why you are doing it.

PROBLEM: Your practice management system includes a chart documentation template which you use on every patient, using the notes section to make any necessary adjustments or comments.

SOLUTION: If you use a template, you MUST adjust it as needed to ensure you are documenting treatment correctly and completely. Making notes in the notes section is not enough!

PROBLEM: Patients are routinely blind-sided by unexpected treatment.

SOLUTION: Spending time with patients discussing their priorities, and your recommendations, can result in thousands of dollars in accepted treatment, instead of a patient who feels like they are playing 'dodge ball' with the doctor. Help the patient want to have the treatment. Proactive communication is key.

For an excellent resource on best practices when it comes to patient records, I highly recommend reading this article from Dentistry IQ. If your practice is falling short on any one or more of these issues you are at risk. Don't let that happen to you, and, as always, please contact me if I can help. Together we can make sure you are prepared if HIPAA comes knocking.

Best Practices for Dental Patient Records