I have frequently reinvented myself over a career that has included hospital dental hygiene practice, dental hygiene faculty at a dental school, and leading three different international companies’ education departments for North America. Most recently, I have created Ultrasonics Plus, a consulting company related to ultrasonic therapies.
A natural fit
Working with a malpractice attorney was another interesting professional endeavor that was a natural fit. After several years’ experience on the Maryland State Board of Dental Examiners, chairing the board’s Discipline Committee as vice president and working with the attorney general’s office on investigations, reviewing records was second nature to me. I consulted with the malpractice attorney, not as an expert witness, but rather to do chart audits and organize specific themes in preparation for expert witnesses to give their opinions.
Getting started
The audit process was quite tedious, as the records were never in a consistent format. The first step was to develop a color-coded spreadsheet. (Color-coding and Excel are my best friends!) This allowed collection of data verbatim from the dental records and grouping it in the spreadsheet. The Excel format allowed for data sorting after the information was entered. This is where patterns could be detected.
Common trends in dental records
The common entries observed included:
- Lack of a diagnosis and the lack of documenting the extent or severity of the patient’s condition
- Lack of diagnostic data such as periodontal charting. Many of the records had only a procedure such as “scaled and polished.”
- Lack of diagnostic-quality images or not using standard-of-care images before procedures such as implant placement. An example would be not taking a CT prior to implant placement and then placing the implant through the buccal plate
- Prescriptions not fully documented on the dose or instructions for the prescribed drug and/or no follow-up on the resolution of the problem
- Documenting treatment on the wrong tooth number/surface (when the tooth documented wasn’t present in the dentition)
COVID-19 has given us the responsibility for even better documentation, which includes documentation of vital stats including temperature as part of the standard of care.
On the other side of the table
When I was working for a periodontist, a patient sued the doctor because she didn’t like the diagnosis. As she explained, “People of her upbringing didn’t get such a terrible disease in their mouth.” Her records were submitted to the scrutiny of the law firm representing her. After her attorney reviewed the records, he advised her to drop the lawsuit. Nonetheless, it did cause our team to do a pulse check. Being prepared and doing the right thing for every patient, every time, proved to have protective results for the practice. You can’t stop someone from filing a lawsuit; however, you can alter the course of the litigation with excellent records that protect you and your practice.
Action steps
As health-care providers, dental hygienists are exceptional at organization. Use your detail-oriented gifts to document the patient’s diagnosis and the care provided. The AAP guidelines on staging and grading of periodontal diseases provides a way to consistently document your patient’s health/disease including the extent and severity.1 Use a consistent format such as SOAP notes (subjective, objective, assessment, plan/procedure) to enter your data.2 This documentation system fits within the ADHA Standards for Clinical Dental Hygiene Practice ADPIED format.3
Perform a random chart audit in your office. You may be surprised by what you find. Whether examining records in your practice or utilizing your organizational skills with a local attorney, it could give you a sneak peek behind the scenes.
References
1. Staging and grading periodontitis. The American Academy of Periodontology. 2017. https://www.perio.org/sites/default/files/files/Staging%20and%20Grading%20Periodontitis.pdf. Accessed June 30, 2020.
2. Six tips for successful SOAP notes. ClinicSource. Apr. 21, 2017. https://www.clinicsource.com/six-tips-for-successful-therapy-soap-notes/?gclid=EAIaIQobChMI_9_Hro-q6gIVMBitBh3xGgL1EAAYASAAEgJqGvD_BwE. Accessed June 30, 2020.
3. Standards for clinical dental hygiene practice. American Dental Hygienists’ Association. Revised 2016. https://www.adha.org/resources-docs/2016-Revised-Standards-for-Clinical-Dental-Hygiene-Practice.pdf.
