PATIENT RECORDS IN ENDODONTICS

Dr. V. Vasundhara2nd year pg

Dept of conservative dentistry and endodontics.

CONTENTS Introduction Importance of dental records Contents of endodontic treatment records Patient information form Medical health history Dental history Diagnosis and progress records Radiographs Evaluation and diagnosis Diagnostic test Treatment plan Informed consent

General principles applied Content and standards for record keeping Contents of dental records Clinical details Improving records Storage and security Electronic records Retention of records Access to records confedentiality record size

Patient record request Patient education pamphlets Postoperative instructions Recording referrals Record correction Legal responsibility mal prophylaxis: importance of record standard of care for endodontics Forensic use of dental records Conclusion references

Introduction

A dental record is the detailed document of the history of the illness, physical examination, diagnosis, treatment, and management of a patient. Dental professionals are compelled by law to produce and maintain adequate patient records. With the increasing awareness among the general public of legal issues surrounding healthcare, and with the worrying rise in malpractice cases, a thorough knowledge of dental record issues is essential for any practitioner.

The ability of clinical practitioners to produce and maintain accurate dental records is essential for good quality patient care as well as it being a legal obligation.

The dental record provides for the continuity of care for the patient and is critical in the event of a malpractice insurance claim.

It should be written with the involvement of the patient or client wherever practicable and completed as soon as possible after an event has occurred. It should provide clear evidence of the care planned, the decisions made, the care delivered and the information shared’.

FUNCTIONDental records should document the following information:

1. Course of the patient's dental disease and treatment by recorded diagnosis, treatment, and prognosis.2. Communication among the treating dentist and other health care providers, consultants, subsequent treating practitioners, and third-party carriers.3. Official professional business record in dental-legal matters documenting a sound plan of dental management.4. Necessity and reasonableness of care and treatment for evaluation by peer review and insurance carriers.5. The standard of care was followed.

WHY MAKE AND RETAIN RECORDS?

Dental records play an essential role in:

(a) documenting the consent provided by the patient;(b) documenting the assessment and treatment of the patient;(c) documenting the advice provided to the patient;(d) assisting with complaint resolution, medico-legal and professional standards reviews; and(e) documenting compliance with insurer, other third party payer and government subsidized dental program requirements.

A record of each occasion of service for a patient is an essential part of the practice of dentistry.

This improves diagnosis, treatment planning, case management and practice administration.

Accurate records assist efficient and complete delivery of care in the event of another clinician assuming that patient’s treatment.

Patient records form the basis for retrieval of treatment details in the case of a dispute or the requirement to provide evidence.

It is desirable that such details provide an adequate contemporaneous record that obviates the need for any later, and possibly questionable, assumptions that a dentist’s ‘usual practices’ were followed in a specific case.

ENDODONTIC TREATMENT RECORDS SHOULD INCLUDE.. Name of patient Date of visit Medical and dental history Allergies and adverse drug reactions Chief complaints Radiographs of diagnostic quality Pulpal and periodontal tests performed Clinical examination findings Differential and final diagnosis Treatment plan prognosis Referrals, including patient refusal (if any) Communications with other health care providers

Progress notes Completion notes Cancelled or missed appointments and stated reasons Emergency treatment Patient concerns and dissatisfactions Planned follow ups Drugs and laboratory prescriptions Patient non compliance Consent forms Accounting Recall notifications E-mail address phone number

PATIENT INFORMATION FORM A patient information form provides data essential for

identification and office communication. Name, address, business address, and telephone numbers arc needed to contact the patient for scheduling purposes or to inquire about postoperative treatment sequelae.

In the event the patient is a minor, the responsible parent or guardian should provide the information

dental insurance and financial responsibility are included to avoid any misunderstandings later and to fulfill federal requirements regarding truth in lending law, applicable if four or more installment payments are arranged. Patient information and history forms should be updated periodically

MEDICAL HEALTH HISTORY

Past and present health status should be thoroughly reviewed by the dentist before proceeding so that dental treatment can be safely initiated

Health questionnaires open avenues for discussion about problems of major organ systems, important biochemical mechanisms, such as blood coagulation, and any immunocompromised need for antibiotic prophylaxis, and disease susceptibility.

the following checklist may be helpful:

• details of past hospitalizations and/or serious illnesses, conditions or adverse reactions;• significant respiratory diseases, e.g. asthma, emphysema, tuberculosis;• any known allergies;• peculiar or adverse reactions to any medicines or injections, e.g. penicillin, Aspirin or local anaesthetics;• heart disease, heart attack, blood pressure problems or stroke;• history of infective endocarditis;• epilepsy or seizures;• blood disorders, bleeding or bruising tendency;• endocrine disorders, e.g. diabetes;• cancer/radiation treatment/chemotherapy;

•hepatitis A/B/C, jaundice, liver disease or gastrointestinal disorders;• kidney disease; immuno-compromising diseases, e.g. HIV positive status, AIDS, leukemias;• nutritional status/eating disorders, e.g. anorexia nervosa, bulimia;

• any prosthetic joints;• medications and supplements taken regularly;• pregnancy;• psychiatric disorders/treatment;• drug or alcohol dependency; and• any other conditions or problems of which the clinician should be made aware.

Any drug allergies, medical alerts or conditions pertinent to the patient’s care should be conspicuously noted in the patient record.

Current medications, medical therapy, and the name and location of the treating physicians are essential.

Updating the medical history requires the practitioner to be apprised of changes in the patient’s medical condition and new medications the patient is taking, including over-the- counter or herbal medications and/or supplements.

Medical histories should be updated periodically.

DENTAL HISTORY The dental history should include past dental

difficulties, name and address of current or most recent treating clinician, chief complaint, relevant prior dental treatment, and attitude regarding teeth retention.

A positive response should suggest further consultation with the patient and consideration for obtaining the prior treating dentist's written records and radiographs for elucidation

DIAGNOSTIC AND PROGRESS RECORDS

Diagnostic and progress records often combine the "fill-in“ and "check-off" types of forms. Fill-in or essay-type forms allow greater latitude of response to a question, resulting in a more detailed description.

One drawback, however, is that it also is open to oversights unless a dentist is very conscientious in noting all clinical information.

An essay-type health history response, alone, is insufficient. Often a patient may not appreciate the significance of important symptoms.

A check-off format is efficient and more practical. such records document missing medical information the patient failed to provide. Therefore, at the end of the check-off portion of the medical history, there should be an essay question so that the patient can provide any other pertinent medical information.

RADIOGRAPHS Radiographs arc essential for diagnosis and also as

additional documentation of the pretreatment condition of the patient.

Diagnostic quality periapical radiographs are essential aids in diagnosis and midtreatment endodontic therapy, to verify the final result, and for follow-up comparisons at recall examinations.

EVALUATION AND DIAGNOSIS Diagnosis includes discussing history of the current

problem, clinical examination, pulpal testing, and recorded radiographic results. If therapy is indicated, the reasons can be discussed with the patient in an organized way. When other factors affect the prognosis (e.g., strategic importance or restorability of the tooth),

the clinician should consider further consultation before initiating any treatment.

DIAGNOTIC TESTS The following endodontics tests should be performed

to arrive at a correct and accurate endodontic diagnosis:

Percussion Thermal testing Electric testing palpation Mobility Periodontal assessmentReasonable clinicians should record all testing results, both positive and negative.

TREATMENT PLAN All treatment provided on a given date is documented by

placing a check mark within the designated procedural category.

Individual root canal lengths are recorded by1. Circling the corresponding anatomic designation and the

method of length determination.2. Writing the measurement (in millimeter) and3. Indicating the reference point. For any medication prescribed, refilled, or dispensed, the treatment record should show the date and type of drug. periodic recall intervals, dates and findings are entered in the spaces provided. e-mail prescriptions and correspondence should be documented with hard copies in the chart or stored in electronic format.

INFORMED CONSENT FORM

After endodontic diagnosis, the benefits, risks, treatment plan, and alternatives to endodontic treatment, including the patient's refusal of treatment, are presented to the patient or guardian. This will document acceptance or rejection of the consultation recommendations.

The patient (or guardian) signs and dates the consent form, including any video informed consent.

subsequent changes in the proposed treatment plan should also be discussed and initialed by the patient, to indicate continued acceptance and to acknowledge understanding of any new risks, alternatives, or referrals.

To obviate a patient’s claim that no explanation ever occurred, a patient questionnaire can additionally be used. Patient can be instructed that unless they score 100%, proposed procedure will not be done.

GENERAL PRINCIPLES TO BE APPLIED(a) Clinically relevant, accurate, contemporaneous records are essential to provide dental care and for forensic purposes.(b) Dentists should take reasonable steps to ensure that the information in dental records is accurate, complete and up to date.(c) Dentists are only permitted to collect information which is necessary for their lawful functions and activities.(d) Records must be sufficiently comprehensible in each entry so that another practitioner, relying on the record, can undertake the patient’s ongoing care.(e) Dental Records should be completed as soon as practicable after the service has been rendered by the dentist.

(f) Entries should be made in chronological order.(g) Entries must be accurate and should be concise.(h) Dental records must be understandable by third parties, particularly other health care providers. Records should be legible and abbreviations standard ones.(i) Dental records must be able to be retrieved when required.(j) All comments must be provided based upon the facts, do not include emotional language or make defamatory statements.k) A treating dental practitioner must not delegate responsibility for the accuracy of medical and dental information to another person.

(l) The treating dentist should ensure that only authorised and suitably qualified persons provide clinical information from the dental record to patients and other persons.(m) Records should be kept for each patient contact.(n) Dentists should protect the privacy and confidentiality of dental records and comply with all relevant Privacy Laws.(o)All entries should be dated and recorded by hand in permanent ink or typewritten, or be in an acceptable electronic format and be complete, clear and legible.(p)All entries, including electronic entries, should be signed, initialled or otherwise attributable to the writer and if different, the treating clinician.

(q)Radiographs and other diagnostic aids, such as study models, should be properly labelled, dated and the interpretation of the findings documented when considered appropriate by the practitioner.(r)An explanation of the overall treatment plan, treatment alternatives, any risks or limitations of treatment and the estimated costs of the treatment should be provided to each patient, parent, legal guardian or government-appointed advocate as appropriate. This fact should be noted in the patient record. In complex or difficult cases, it is advisableto have such informed consent signed.

Adopted by ADA Federal Council, November 15/16, 2012Dental record keeping guidelines, cdsbc

CONTENT AND STANDARDS FOR RECORD KEEPING:(a) Patient details: Sufficient information to identify and communicate

with the patient should be recorded, including:

(i) identifying details of the patient (full name, sex, date of birth and address, including email and telephone number); and(ii) the current medical history of the patient, including any adverse drug reactions.

b) Substitute decision maker If the patient is a child or under the care of a legal

guardian or substitute decision maker, the dental record should contain the name, address and contact details of the parent, guardian or substitute decision maker and the relationship of the substitute decision maker to the patient.

(c) Consents and restrictions on disclosure

THE DENTAL RECORD SHOULD INCLUDE:(i) a record of consents provided by the Patient.;(ii) if written consent is provided, the signed consent form;(iii) If a patient information sheet has been provided to the patient, a copy of the patient information sheet or reference to the name and version/date of the patient information sheet;(iv) if written consent is not provided, then: (A) a description of the treatment as explained to the patient; and (B) the consents provided by the patient, including consent to treatment, privacy consents and financial consent;

(v) advice given to the patient on: (A) treatment options; (B) the relevant material risks and benefits of those options; (C) pre- and post-treatment instructions; (D) likely outcomes;(vi) relevant questions, comments or concerns expressed by patients over offered treatments;(vii) any treatment advice that the patient was unwilling to accept;(viii) any comments or complaints by patients about treatment provided;(ix) if there are any restrictions on disclosures, including in relation to any directions from the patient or family law restrictions;

(x) if the patient has made a direction in relation to care, such as a restriction on blood transfusions, etc;(xi) subject to discrimination laws, for workplace health and safety reasons, you may wish to include a “flag” on the medical record for the treating provider within your dental practice to contact you, for example, if a patient has previously displayed aggression or inappropriate behaviour towards staff so that appropriate staff can be involved in treating the patient;(xii) if English is not the patient’s first language, if an interpreter is required to treat the patient.

CLINICAL DETAILS: clear documentation describing:(A) the date of visit;(B) the identifying details of the practitioner providing the treatment;(C) information about the type of examination conducted;(D) the presenting complaint;(E) relevant history;(F) clinical findings and observations;(G) diagnosis;(H) treatment plans and alternatives;(I) consent of the patient, client or consumer;(J) all procedures conducted;

(K) instrument batch (tracking) control identification, where relevant(L) a medicine/drug prescribed, administered or supplied or any other therapeutic agent used (name, quantity, dose, instructions);(M) details of advice provided

Other details all referrals to and from other practitioners; any relevant communication with or about the

patient, client or consumer; details of anyone contributing to the dental record; estimates or quotations of fees. Records should also indicate when the patient failed

to attend and provide for adequate follow up

How to improve record-keeping?

By adopting the following habits, nurses should avoid problems related to record-keeping:

- Get into the habit of using factual, consistent, accurate, objective and unambiguous patient information;

- Use your senses to record what you did, such as ‘I heard’, ‘felt’, ‘saw’, and so on;

- Use quotation marks where necessary, such as when you are recording what has been said to you;

Ensure there is a reasoned rationale (evidence) for any decision recorded, for example, denying access to a visit from children;

- Ensure notes are accurately dated, timed, and signed, with the name printed alongside the entry (initials should be avoided);

Follow the SMART model (Specific, Measurable, Achievable, Realistic and Time-based) or similar when planning care;

- Write up notes as soon as possible after an event and, by law, within 24 hours, making clear any subsequent alterations or additions;

- Document any objections you may have to the care that has been given;

- Do not include jargon, meaningless phrases (for example ‘slept well’), irrelevant speculation, and offensive subjective statements;

- Write the notes, where possible, with the involvement and understanding of the patient or carer .

STORAGE AND SECURITY OF RECORDS

Dental practices must take reasonable steps to protect the personal information it holds from misuse and loss and from unauthorised access, modification or disclosure.

Dental records should be securely stored, protected from unauthorised access or use. All file cabinets should be locked and kept in a room which is not accessible to the general public.

All computers should be password protected. Information technology systems should have appropriate security software installed.

Dentists should ensure records are maintained on durable paper, some forms of medical photographic imaging fades with time and should be copied.

Dental records can be sent by secure fax or email. When sending dental records by post, traceable methods should be used such as registered mail or express post.

If a health record is destroyed after the required retention periods, it must be destroyed in a secure manner, such as document shredding.

ELECTRONIC RECORDS

It is important that any electronic recordkeeping system employed in a dental practice:

has a login and password to access the data, or otherwise provide reasonable protection against unauthorized access, and can authenticate all entries;

provides an accurate visual display of the recorded information and is capable of retrieving and printing this information within a reasonable time period;• has an audit trail that:–– records the author, time, date, workstation (for networked systems) of each entry for each patient with respect to the clinical or financial data entry, and is capable of being printed separately from the recorded information for each patient;––

preserves the original content of the recorded information (text, image or chart) in a readonly format that when changed or updated tracks the author, time, date, and workstation (for networked systems) of the modification;

provides a means of visually displaying the clinical and financial records of each patient by patient name and is easily printed or transferred with the inclusion of all of the original and modified entries, and the dates, order of entry and authors;

• has the capability to provide good quality printed copies of the records and digitized images;

• stores the original data in a read-only format from within the dental program itself, but protects the data files from entry and alteration from the database;

• backs up files on a removable medium that allows data recovery, or provides by other means, reasonable protection against loss, damage, and/ or inaccessibility of patient information; and

• ensures the privacy of the patient’s personal information is properly safeguarded in both the electronic recordkeeping and in the transfer of the patient’s records.

Other necessary functional requirements of electronic records are:

1.a dental practitioner’s records must show who made each entry and when it was made;2. it must not be possible for entries to be changed without trace, that is, there must be an audit trail3.there should be security procedures such as access being available only by password4.there must be a standard procedure for entering treatment record data that is recorded in an office manual or memorandum to the practitioner’s staff; and there must be adequate computer back up and disaster recovery systems in place

RETENTION OF RECORDS

Dental records should be retained:

In the case of health information collected while the individual was an adult – for at least seven years from the last occasion on which a health service was provided to the individual by the health service provider;

in the case of health information collected while the individual was under the age of 18 years – at least until the individual has attend the age of 25 years.

If you delete or dispose of health information, you must keep a record of the name of the individual to whom the health information related, the period covered by it and the date on which is was deleted or disposed of.

A health service provider who transfer health information to another organisation and does not continue to hold a record of that information must keep a record of the name and address of the organisation to whom or to which it was transferred

A health record may be kept in electronic form, but only if it is capable of being printed in paper.

Unless required by law, or an agreed transfer of records to another treating practitioner, copies and not originals of records should be released. If original records are released, dental practitioners should obtain an acknowledgment receipt and also retain copies for their own records.

Diagnostic images and reports should be kept as part of the dental record. It is a reasonable alternative that diagnostic images and diagnostic casts be given to the patient for retention.

Subject to mandatory retention requirements, dentists must take reasonable steps to destroy or permanently destroy or permanently de-identify personal information if it is no longer needed for any purpose for which the information may be used or disclosed under Privacy Laws

ACCESS TO RECORDS

The dentist (or the dental practice) owns the dental records.

Copyright in dental records may or may not exist depending upon the circumstances and the complexity of the entry.

Under Privacy Laws, if a dentist holds personal information about an individual (including a patient), it must provide the individual with access to the information on request by the individual

unless a specific exemption applies.

The exemptions include:

In the case of health information, providing access would pose a serious threat to the life or health of any individual. In this case, dental records may be provided to another dental practice to explain to the patient; or the record is covered by legal professional privilege (which would not apply to ordinary dental records but may apply to a medico-legal report written by a dentist).

Access may include providing the patient with a copy of the dental records.

If a dentist charges for providing access to personal information, those charges: must not be excessive; and must not apply to lodging a request for access

In some States, the costs are regulated under State Privacy Laws.

It is recommended that when a patient seeks to access their dental records, the dentist offers to meet with the patient and explain the records to them.

It is preferable that the information should be provided in a report, and not simply by sending a copy (never an original, unless an original is required by court order) of the records. A report written for the express purpose of the request may be far more helpful than the records themselves.

If a dentist holds personal information about an individual and the individual is able to establish that the information is not accurate, complete and up-to-date, the dentist must take reasonable

steps to correct the information so that it is accurate, complete and up to date.

If the individual and the organisation disagree about whether the information is accurate, complete and up-to-date, and the individual asks the dentist to associate with the information a statement claiming that the information is not accurate, complete or up-to-date, the dentist must take reasonable steps to do so.

A dentist must provide reasons for denial of access or a refusal to correct persons information.

CONFIDENTIALITY

Patient information and dental records contain sensitive personal information and must be kept in confidence. A patient’s personal information and dental records must be protected from any unauthorized use or disclosure, except as required by law or where the patient has given their express consent, ideally in writing.

Dentists are also responsible for ensuring that their staff is aware of the requirement of maintaining confidentiality with respect to patient information and dental records. Dentists and their staff must also be aware of the requirement for patient consent before the disclosure or transfer of any patient information or dental records to any third party, including to other family members.

Confidentiality requirements apply to paper, electronic, and other forms of patient information and dental records.

Records should be stored securely, not left unattended or in public areas of the office, and destroyed appropriately and securely at the end of the required retention period

RECORD SIZE Although there is little harm in recording too much

information, there is great danger in recording too little. Standard 8 ½ * 11 inch or larger clinical records possess the advantage of providing the treating clinician adequate space for clinical notes.

PATIENT RECORD REQUEST

Patient requests for records must be honored. It is unethical to refuse to transfer patient records, upon patient request, to another treating clinician.

Moreover, refusing to provide patient records is illegal in some states, subjecting the clinician to discipline and fines should the records not be provided to the patient upon written request, even if an outstanding balance is owed.

PATIENT EDUCATION PAMPHLETS Patient education pamphlets may be utilized in

litigation as evidence that a patient who was properly informed and given endodontic alternatives, instead chose extraction.

Such pamphlets include the ADA's "Your Teeth Can be

Saved by Endodontic Root Canal Treatment" or the AAE's "Saving Teeth Through Endodontic Therapy." Indicate in the patient's chart that the patient was shown or given the pamphlet(s).

POST OPERATIVE INSTRUCTIONS It is unlikely a patient will remember oral post

operative instructions unless accompanied with written instructions.

After endodontic procedures, the patient may be sedated or affected by analgesic drugs. Accordingly, written post operative instructions are beneficial.

Emergency phone numbers to contact the treating clinician should be included on the form.

RECORDING REFERRALS If consultations with additional experts or specialists

become necessary, referrals should be recorded lest they be forgotten or refused. Carbonless, two-part referrals cards allow the clinician to provide an original referral slip to the patient while retaining a copy for the patient’s chart.

The clinician or staff member should document the fact that the original referral card was given to the patient and record the name of the person who provided the referral card and the date on which it was provided.

the clinician should request that the patient and referred clinician report back if the referral appointment is canceled.

RECORD CORRECTION Records must be complete, accurate, legible, and

dated. All diagnosis, treatments, and referrals should be recorded.

To correct an entry, the clinician should make a line through ( but not erase or obscure) the erroneous entry. The correction should then be written on the next available line and dated.

If records are proven to be falsified, the clinician may be subject to punitive damages in civil litigation. In addition, the clinician may be subject to license revocation for intentional misconduct.

LEGAL RESPOSIBILITIES

MAL PRACTICE PROPHYLAXIS: IMPORTANCE OF RECORDS Records represent the single most critical evidence a

clinician can present in court as confirmation that an accurate diagnosis, proper planned treatment, and informed consent were provided.

Prevention is the goal of modern dental care.

Competent endodontic treatment performed within the requisite standard of care not only saves endodontically treated teeth but also helps prevent a lawsuit for professional negligence.

STANDARD OF CARE FOR ENDODONTICS Endodontists should not forget their general clinician

training. Even though a patient may be referred for a specific procedure or undertaking, the endodontist should not over look sound biologic principles inherent in the overall treatment.

Endodontist should not provide rubber-stamp treatment to whatever the clinician refers or recommends. Without performing an independent examination, the endodontist risks misdiagnosis and resulting incorrect treatment.

Radigraphs from the referring clinician should be reviewed for completeness, clarity and diagnostic accuracy. An endodontist should expose a new radiograph to verify current status before treatment.

It is necessary for the endodontist to: Be alert to any contributory medical or dental

condition within the operative area of endodontic treatment that can affect treatment.

Undertake an independent diagnostic and radioghraphic examination of the treatment area and the treatment plan rather relying solely on the referring clinician.

Perform a general dental examination to diagnose any hard and soft tissue pathosis.

Evaluate status and prognosis of adjacent and opposing teeth.

Advise the referring clinician and patient of pertinent findings.

FORENSIC USES OF PATIENT RECORDS

Dental records also provide valuable ante mortem records to forensic odontologists. Forensic dentistry is the overlap of dental and legal professions. Forensic dentists are frequently called upon to identify the remains of individuals who cannot be identified visually.

The identification is usually carried out by comparison

of ante mortem and postmortem records. The identification of diseased individuals is an essential element in the process of death certification and is crucial component in the investigation of homicides or other suspicious deaths.

CONCLUSION Doubt about what should be documented or how

records need to be kept, practitioners should ask themselves: “Will this action serve the best interests of my patient? Does this action helps in my patient’s safety and the continuity of his or her dental care?”

The principles applying to handwritten records also apply to computer records, for example, entries must be date, time, and operator-stamped, all changes made must be traceable, and any codes used must be readily convertible to conventional language.

Records must be readily accessible and understandable data needs to be controlled, for example, via use of passwords.

The production, retention, and release of clear and accurate patient records are an essential part of the dentist’s professional responsibility. Success in this task will assist the dentist for a medicolegal claim be made and can assist the police and coroners in the correct identification of individuals.

REFRENCES Pathways of pulp cohen tenth edition Ingle text book of endodontics 6th edition Dental record keeping guidelines, college of dental surgeons

of british columbia april 2013. B K charangowda Dental records: An overview J Forensic

Dent Sci. 2010 Jan-Jun; 2(1): 5–10 DENTAL RECORDS (Including ADA Guidelines for Dental

Records)