Recordkeeping, Documentation, and Patient Rights
This domain tests whether the record would support the care you provided, and whether you can handle a records request without violating either the patient's rights or the Board's rules.
What belongs in the record
- Medical history and updates, medications, allergies, and consent for treatment.
- Charting of existing conditions, periodontal findings, radiographs, and dated progress notes for each visit.
- Anesthesia and nitrous oxide records: agents, doses, monitoring values, and patient response.
- Referrals made, advice given by telephone, missed appointments, and any refusal of recommended care.
How to keep it defensible
- Entries are contemporaneous, dated, and authenticated by the person who made them.
- Corrections are made with a single line, the correction, the date, and initials, so the original remains readable. Electronic records must preserve an audit trail.
- Retention must satisfy Board rules and the period during which a patient could bring an action; pediatric records are generally kept longer.
- The record belongs to the practice, but the patient has a right of access to a copy.
Patient rights
- Informed consent, including the right to refuse and to be told the consequences.
- Confidentiality, with release only on valid written authorization or legal compulsion such as a subpoena.
- Minors: consent and access run through the parent or legal guardian, subject to state law on specific services.
Worked example. A former patient requests copies of her chart; the practice has an unpaid balance. Reasoning: an unpaid balance is a business dispute and is not a lawful basis to withhold records. Provide the copy under the authorization process and pursue the balance separately.
Traps that cost marks
- "Fixing" an error by erasing or backdating an entry.
- Charting a treatment plan the dentist never made.
- Releasing records on a phone request without written authorization.