The purpose of complete and accurate patient record documentation is to foster quality and continuity of care. It creates a means of communication between providers and between providers and patients about treatment, planning and delivery of care.
Although most dental patients’ records begin with a high level of quality, it is unfortunately not uncommon for the quality and substance to diminish after the initial visits. You should make sure your records comply with state law or regulations.Generally speaking, you should maintain accurate and complete records for each appointment. Your records should be made contemporaneously with the patient’s treatment to ensure accuracy.
Re–examine your patient history forms to ensure they sufficiently address the background information you will need to properly treat your patient. Be sure your patient history is up to date with current conditions and medications noted. It’s also important to ensure your records are maintained in a HIPAA–compliant manner and your patients receive your Notice of Privacy Procedures.
If you need to correct an entry in a chart, consider making a specific notation that you have revised the record and explain why (note that the operative word is "correct" — not "change"). Be sure to initial any revision or correction. Do not "squeeze in" notes or use different pens for the same chart note, and do not use correction fluid.
It is not unusual for a malpractice attorney to hire an expert document examiner to analyze chart notes when it appears a record may have been changed or a post–entry note added (including sophisticated analysis of the ink appearing on the original). Evidence of an altered record could be fatal to the defense of a malpractice claim. Without explanation in the records as to why a chart notation was corrected, an altered record implies a cover–up. It could constitute the proverbial "smoking gun" that every plaintiff’s attorney hopes to uncover. The same recommendation, of course, would extend to records maintained on a computer. A knowledgeable computer expert will likely be able to ascertain whether a file has been revised or altered.
If a request for your records is made, document in the file when and to whom the records were released. Because treatment records are supposed to be made contemporaneously with the treatment, avoid making any post–release entries into the records (other than, of course, for subsequent treatment). Never make any changes or revisions once the records have been released to any third party unless it is absolutely imperative you need to document a correction as noted above.