The Importance of Recording the Clinical Record

The “clinical record,” the “dental record,” and the “medical record” are all terms that apply to information that details the printed and/or written information gathered, collected, and/or used during the course of ascertaining a diagnosis and rendering treatment for a given patient by a health care provider and/or providing entity (e.g., group practice, hospital, clinic, etc.).

For purposes of simplicity, the term “record” will be used in this article to refer to this collection of information. The general purpose of the clinical record is to tell a clear, concise, and accurate story about the events that occur under the provider’s care.

What is in the clinical record?

The items that make up the record have changed over the decades as understanding of healthcare processes has changed and due to the advent of technological means of record keeping. For instance, at one time, it was common practice to simply record when a patient was seen with a brief description of what was done. When I was in dental school, I was taught that the financial records were not to be considered part of the record (instead, they were referred to as the “financial record”) because financial issues were not considered to be part of the treatment rendered to the patient.

However, the definition of what is included in the record is changing as the concept that the financial abilities and associated choices (referred to as socioeconomic status) has been incorporated into the evidence-based dentistry model, and because dental practice management software programs virtually marry financial and clinical information together with a keystroke or two. As the diagram below shows, the concept of evidence-based dentistry involves the patient's input into treatment rendered, which depends on proper informed consent.

Furthermore, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), reinforced by the Final Omnibus Rule of 2013, confuses the definition of the record with atypical terms to the average clinician’s vocabulary:

• Electronically protected health information (ePHI):  Material that is created, received, used or maintained by a covered entity regarding a particular patient, which may include photographs, e-mail, digital treatment records, digital radiographs, etc.
• Protected health information (PHI): Individually identifiable health care information in any form, which may include photographs, written paper forms or spoken word
• Designated record set:  A group of records maintained by or for a covered entity, which may include treatment records, billing records, insurance records, case management records, and/or any other record that is used in any way for a covered entity to make decisions about the care of a particular patient.

While HIPAA is well outside the scope of this article, suffice it to say that the record includes any and all information related to the care of a patient while under the care of a provider or a providing entity. The lines are blurred defining the record. Furthermore, under federal legislation, the patient also has a right to copies of their record, or “designated record set,” within a defined period of time (within 30 days typically) and to be able to amend their record if they disagree with what is recorded. Therefore, it is imperative that clinicians keep excellent notes and documentation of any treatment rendered.

When records are requested for legal purposes, it is often wise to request a clear list of what is to be included in the record and then consult an attorney experienced in dental issues to verify and make recommendations as to what must be provided because there may be information that cannot be provided without additional actions (e.g., psychiatric records). The requestor of a dataset must be clear about what they are requesting as part of the designated record set, but it is important for a provider not to make it difficult for a person to get a copy of their record. For example, requiring a patient to physically come to an office to get a copy of their record may be a violation of HIPAA under the latest guidelines from the Office of Civil Rights. 

Following is a list of common items often considered to be part of the record:

• Examination findings
• Radiographs (including CBCT) and findings
• Radiology reports
• Photographs
• Study models (identify articulator used if mounted)
• Treatment notes
• Treatment plans
• Health history forms and records of discussion
• Consent forms used and/or documented discussions regarding informed consent and Refusal
• Physician and specialist consultation reports and/or summaries of conversations with physicians and specialists
• Proof of referral (include copy of form if used)
• Financial arrangement forms
• Ledger
• Documentation of referrals from other clinicians
• Requests of for information
• Copies of all written correspondence with patient

Additionally, a general record of standard recall postcards, new patient letter, advertisements, saved copy of the practice website, informational brochures, etc., should also be kept in the office that can be reproduced if requested or demanded, which all document part of the informed consent process.

Working with a clinical records request

When a simple “records request” is made from a patient because they are transferring to another practice, they should still identify what they would like. Commonly, they simply request that their “records” be transferred to another dentist. In this case, a phone call to the new dentist may be appropriate because not every dentist will want all of the information, but rather they would prefer to only have what is necessary to assure continuity of care (e.g., only periodontal comparison, a written summary of the condition of the patient, most recent radiographs, etc.). In such cases, it might be prudent to simply inform the patient and the new practice that more extensive records are available upon their written request. It is important to remember that HIPAA does not distinguish between a simple records request for transferring to a new dentist and providing records for legal analysis. The patient is responsible for requesting and authorizing the designated record set.

The record must tell a clear story about a patient's time under his/her dentist’s care, readable by any person with basic clinical knowledge.  While dentists are often taught that all findings must be recorded for accuracy, including the normal findings, that’s not realistic. It’s much more common to chart by exception, which is a legal term for recording atypical findings. Of course, normal recording may also be recorded if the clinician chooses, but the forms for data collection or customized templates should at least indicate the field that prompts the clinician to evaluate the normal even if it’s not recorded. The clinician must remember that those people reading the record may be other dentists or physicians, chiropractors, nurses, receptionists, insurance clerks, board investigators and board members who may have limited dental knowledge, insurance claims adjusters, etc.  Most importantly, the clinician needs to be able to easily and accurately read his/her own record! 

As examples, which of these actual records would you think best reflects the dentist’s actual quality of care for his/her patient?

or …

The record is used for a variety of purposes while the patient is being treated and even after death. Aside from the obvious uses for the record from a medicolegal perspective, for billing and reimbursement, and for continuity of care, the record is also a valuable forensic tool for legal defense or to assist in identification of missing persons. For example, accurate radiographs and charting of existing restorations can be used along with programs like WinID to assist in timely identification of deceased individuals. As an example, the quality radiographs below were useful in a rapid identification of a victim of a fire by comparison of anatomic features, a piece of residual amalgam that had also been documented in the record in writing, and bone topography of fragments recovered from the scene.

The record is an essential element in ensuring the health of the patient through continuity of care; in the accurate telling of a story about the care of a patient; in justifying the thought processes and measures of care taken by the provider; and in providing critical information for assistance with many matters beyond the scope of a single dental appointment.

(Click this link to read more dentistry articles by Dr. Kevin Huff.)

Kevin D. Huff, DDS, Spear Moderator and Contributing Author - www.doctorhuff.net