Gloves Off: Documentation—fast and effective ways to get it done

July 21, 2022
Dr. David Rice and Tija Hunter talk about how accurate documentation can help protect you from legal action. Remember—if it’s not written in the chart, it didn’t happen.

One of the areas in dental practices today where we aren’t where we need to be is documentation. Doctors must review chart notes daily and make sure their dental assistants know what to document.

The documentation that we sign off on is evidence in a court of law. If ever questioned by a lawyer, judge, or dental board, you want to make sure your chart notes are accurate and professional. There absolutely must be a system and process in place for documentation, because if it’s not written in the chart, it didn’t happen.

In this episode of Gloves Off, we’ll talk about tips for keeping accurate chart notes that will help protect you from legal action.

Join us as we take our gloves off and strive to become better!

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Editor’s note: This article first appeared in Through the Loupes newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe to Through the Loupes.

About the Author

David R. Rice, DDS | Chief editor

Founder of the nation’s largest student and new-dentist community, igniteDDS, David R. Rice, DDS, travels the world speaking, writing, and connecting today’s top young dentists with tomorrow’s most successful dental practices. He is the editorial director of DentistryIQ and leads a team-centered restorative and implant practice in East Amherst, New York. With 27 years of practice in the books, Dr. Rice is trained at the Pankey Institute, the Dawson Academy, Spear Education, and most prolifically at the school of hard knocks. Contact him at [email protected].

About the Author

Tija Hunter, CDA, EFDA

Tija Hunter, CDA, CDIA, CDIPC, CDSH, CDSO, EFDA, MADAA, is a member and former vice president of the American Dental Assistants Association (ADAA), where she holds the honor of Master. She is the director of the Dental Careers Institute, a dental assisting and dental continuing education program, and the author of seven continuing education study courses. She is an international speaker and a certified trainer in nitrous oxide in several states. She can be reached at [email protected].

Updated January 12, 2024