To Document or Not to Document
That is the question

By Robyn Thomason
Risk Management Analyst, TDIC

Risk management presenters repeatedly instruct dentists about the importance of proper documentation. At the end of most seminars, the final words of wisdom are typically: document, document, document. There are some things, however, that do not belong in the patient’s chart. So how does a dentist know what details are essential and what details could be damaging?

Appropriate documentation provides treatment continuity. Any health care provider should be able to pick up a patient’s chart and know what dental treatment the patient has undergone and be able to continue with remaining treatment. However, not all information obtained from the patient is treatment related and if documented in the patient’s chart could pose a problem. Patients and their attorneys can obtain a patient’s record; therefore, all information in the chart is discoverable and not privileged. Some of those items that do not belong in the patient’s chart include:

•  Financial information. The cost of treatment and the patient’s payment history can influence how care is perceived. References to cost may have the appearance that the dentist is more concerned with finances than treatment. Dollar figures can encourage a plaintiff’s counsel to focus on cost instead of care. Therefore, financial records should be kept in a file separate from the treatment record.
  
• Documentation regarding any discussion with your attorney or liability carrier regarding a particular situation. These discussions may be interpreted as defensive rather than a desire to do the right thing for the patient. Plaintiff’s attorneys could use such entries to suggest that dentists knew they had done something wrong and contacted their malpractice carrier for protection. While these types of conversations are important and should be documented, keep them in a separate file. They are privileged and confidential unless they are put in the treatment records. 
  
• Critical or subjective comments about the patient. The chart should only include relevant, factual comments regarding the patient’s health and treatment. When documenting a negative conversation or comment from the patient, be sure to directly quote the patient.

The information in a patient’s chart is the first line of defense when facing allegations of negligence. However, you do not want to keep information that distracts from clinical decision-making in the treatment record. Ask yourself, “would I be comfortable with this entry being enlarged and projected on a screen in front of a jury?” While it may be important, it is best to keep it separate from the record maintained for your attorney or insurance carrier.