Choosing to open and operate your own dental practice can be extremely rewarding, but it is not without its challenges. Most people who operate a dental practice do so because they have a passion for oral health and a great deal of skill, but may not have much experience in risk management and daily operations.
Maintaining accurate dental records is an important part of not only providing care, but also protecting your practice. In the event that you're faced with a malpractice accusation, having clear and easily proven records can be very important. Below, you'll find a guide to some tips for record maintenance, providing you with the opportunity to keep yourself sufficiently protected.
Basic chart recording techniques should always be followed to guarantee that your records are easily readable. While there's an old trope concerning doctors and poor handwriting, it's important that you use clear, block print that can be easily understood and transferred from doctor to doctor.
You should also make sure all entries are dated as well as chronologically organized, as this is the easiest way to chart the progress of a patient's treatment. On a related note, be sure that every entry is signed or initialed, as it will allow you to go directly to the doctor who provided the treatment if you have any questions.
Even the most diligent of doctors can make simple errors when transcribing notes to a chart. When this occurs, it's important that you note the error while still allowing the original notation to remain visible, as any possible discrepancies need to be easily traced.
When crossing out information on a chart that is inaccurate, you should use a single strike through and be sure to sign and date the correction. This will be a strong signal that the alteration was intentional, but should also make it abundantly clear that no deception or malpractice occurred to necessitate the change.
Perhaps the most common mistake made in dental records is disposing of those records prematurely. Even if a patient informs you that he or she is transferring to the care of another doctor, it's important to maintain a copy of the records in case they later become relevant. You should also be sure to retain the records of a deceased patient for a period of time, as the process of settling his or her estate may occasionally require a review of their medical records.
To learn about other ways to protect your practice from a malpractice suit, contact an insurance company like HMBD Insurance Services.