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Auditing of Dental Records

04 February 2019
When a patient makes a complaint, it is common for this to be followed by the regulator mandating an audit of your records. What are they looking for, and how best can you prepare?

The lead document for dental practitioners regarding their record keeping is the Dental Board’s Guidelines on Dental Records. This will show you what the Dental Board expectations are regarding your record keeping. Essentially, an audit of your records would involve comparing this guidance to your own records and seeing if there are any deficiencies. You may wish to draw up a spreadsheet from the guidance, and then choose a random selection of records to do a quick comparison and identify any gaps.  The purpose of this document is to assist you in this process.

The guidelines set out our responsibilities as practitioners relating to the collection, safe storage, transfer, retention, access to and, where appropriate, destruction of all dental records. In addition to this, the guidelines describe the expected content of the records:

Patient details

Here you need to include the patient’s name, address and date of birth. In addition, it is important to have a current medical history form completed and updated at appropriate intervals. This medical history needs to include not only the patient’s current conditions and medications, but also any reported adverse drug interactions.

Additional advice

The patient completes a medical history form at predetermined intervals, and then the medical history is checked verbally at every visit. Your records need to reflect this, even if there is ‘no change’ or ‘NAD’.

Clinical details

i) The date of the visit

Naturally, computer-generated records auto-populate this, while manual records do not, and care must be taken to ensure this is always accurately recorded.

ii) The identifying details of the practitioner providing the treatment

Many of us using computerised records have a unique identifier built into the system, which serves to act as an electronic signature. If that is not particularly personalised, and is quite generic, you may wish to consider also initialling or signing your electronic entries. Item 3.3 c) of the Guidelines also states that records need to contain the details of anyone contributing to those records, so any notes made by dental assistants or front office staff need to be signed/initialled. 

When auditing your records, check that all the entries are signed. If multiple people have spoken to the patient, is it clear who they were? In addition, if multiple practitioners have provided treatment to the patient, is it clear who did what and when? If not, then your records likely do not meet the required standard. 

iii) Information about type of examination conducted

Seemingly innocuous, this area is a common pitfall for practice. It is critical that you code your examination correctly, whether it be an initial (comprehensive) examination, a recall examination or an emergency examination.

When auditing your records, check that you’ve entered the ADA Glossary code that best describes the examination you undertook.

‘Upcoding’ (the entering of a higher value code, for the purposes of increasing the financial benefit to the practice) can be classified as fraudulent behaviour, and is something that the health funds and Medicare are specifically monitoring. Remember – they can claw back the funds for ‘inappropriate claims’, so protect yourself from this by using the correct codes for treatment claims.

iv) The presenting complaint

A commonly missed area, it is helpful to know why the patient has attended, particularly if they have an aesthetic concern, or are attending for elective treatment.

v) Relevant history

Following on from the above, if the patient attends with pain or a problem, what is the history of this? What is the patient’s medical history? Do your records reflect when this was last updated, and what you found? Is the patient’s social history relevant? Or perhaps their dental history?

The patient’s presenting concerns, and their reported history of this, are a critical component of the patient record, as are all relevant elements of the patient history. 

vi) Clinical findings and observations

This can include the odontogram, the patient’s periodontal health (including a PSR) , noting of caries teeth or teeth of a guarded prognosis, the patient’s oral hygiene, an orthodontic assessment, an assessment of the patient’s TMJ and airway.
The more information you capture, the better the quality of the patient’s records will be and the more likely it is that they will pass audit.

vii) Diagnosis

Before we commence treatment, it can be helpful to record a diagnosis, or provisional diagnosis.

viii) Treatment plan and alternatives

Particularly pertinent in treatment with multiple options, such as save or extract decisions. Remember, no treatment is often an option that can be given to patients, especially in elective or cosmetic treatments. 
If the patient’s presenting complaint, history of this, your diagnosis and treatment plan are not recorded in your clinical notes, it is unlikely that they would pass audit.

ix) Consent of the patient, client or consumer

This may include a consent form; however, it is crucial to remember that this is NOT what is meant by ‘consent’. The expectation of the Dental Board is that your conversation of consent be recorded in your clinical notes including all risks and warnings given to the patient regarding each option, all advantages and disadvantages of each treatment option and also the financial consent.

Consider – should the patient be offered a referral to a specialist? If this is offered and they refuse, their refusal of this should also be documented. What about if the treatment fails? Will this require a specialist assessment, and if so, will there be extra out of pocket expenses for the patient? Naturally, documentation surrounding this not only assists in the audit process, but also saves a lot of heartache in failed treatment cases. 

An allegation of ‘no consent’ is often the root cause of a complaint or legal claim. Consequently, it is imperative that we document this correctly. When assessing your records, consider – is it clear what was discussed with the patient, and the options they were given?  

x) All procedures conducted

Everything undertaken (and charged for) must be listed. If for example you take photographs, you need to indicate in your records WHY they were taken.
Also, the specific materials used must be listed – so rather than ‘composite filling’ the notes should set out the process you followed and the specific materials used (brand name).

xi) Instrument batch (tracking) control identification, where relevant

The lead guidance on this is the Dental Board Guidelines on Infection Control   
Please contact Dental Protection immediately if you are unsure what this means.

xii) A medicine/drug prescribed, administered or supplied or any other therapeutic agent used (name, quantity, dose, instructions)

A common pitfall, as writing ‘LA’ is no longer enough to meet the standard and pass audit.

Documentation in your records of medicines administered and medicines prescribed needs to include:


Practitioners have failed audit for not documenting, for example, the concentration of fluoride used.

xiii) Details of advice provided
Particularly pertinent in any clinical scenario where the patient has been advised to ‘do something’, whether this be care of an appliance or oral hygiene instructions. However, advice can be quite broad in nature, and all advice should be recorded.

Section 3.2 goes on to list the following:

b) Unusual sequelae of treatment
Anything unexpected should be recorded here. One issue Dental Protection commonly sees that leads to failure at audit, is the records are silent on adverse outcomes that arose. Remember, records ‘record’ history, they do not create it – if something unexpected happened during the patient’s treatment, whether it be as simple as syncope, or more severe, this needs to be documented in the records, alongside the steps you took and the advice you gave, plus any required follow up.

c) Radiographs and other diagnostic data
When being audited, it is not only the presence or absence of these which is assessed, but also whether your records reflect that you read the radiograph, and contain your findings – even if that is NAD.

d) Other digital information including CAD-CAM restoration files
If you use scanners, or CAD-CAM, these files need to be retained for the same amount of time as the rest of your records.

e) Instructions to and communications with laboratories 
Don’t throw your lab sheets away! Either save your copy if you have paper files, or scan into the system if you are computerised.

Although self-explanatory in nature, for completeness we have included details of section 3.3, which requires:

a) all referrals to and from other practitioners
b) any relevant communication with or about the patient, client or consumer
c) details of anyone contributing to the clinical record (discussed above)
d) estimates or quotations of fees


iThe Dental Protection workshop ‘Dental Records for Dental Practitioners’ also provides a helpful audit tool. Click here for more information.

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