Foresight should be "20/20"

American journalist and writer Guy Bellamy once said, "Hindsight is an exact science." In today's hectic, fast-paced practice environment, this is a lesson often learned by professionals who fail to adequately document the treatment records of their patients. However, by adhering to a few simple, straightforward rules and by consistently documenting patient records, even the busiest practice can help protect itself from an unhappy patient or his or her assigned representative.

Patient Record...

• Documentation of PARQ (or equivalent)
• Documentation of definitive diagnosis
• Chart description of treatment of services rendered
• Date and description of treatment complications
• Date and description of all radiographs, study models, and periodontal charting
• Documentation of initial health history and any updates
• Date, name of, quantity, and strength of all drugs dispensed, administered, or prescribed.
• Documentation of anesthesia
• Documentation of patient’s choice of less than optimal treatment
• Documentation of declined treatment
• Documentation of dental nexus for Rx.

While by no means exhaustive, the list above outlines some major areas of attention in a patient’s record. By consistently addressing the necessary areas of a patients record, a dental professional can eliminate or minimize treatment questions posed by a patient, an attorney, or a governing board. At DBIC, we believe foresight, and not hindsight, should be “20/20”.

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