One of the most common oversights noted in appeals cases is the lack of information in the patient record. Every dentist with a practice in Florida must maintain written dental records and medical history records that justify the patient’s course of treatment. The Florida Board of Dentistry just issued an update to dental recordkeeping requirements:
The dental record shall contain sufficient information to RECORD EACH PATIENT/DENTIST IN PERSON OR TELEDENTISTRY ENCOUNTER, identify the patient, support the diagnosis, justify the treatment, and document the course and results of treatment accurately by including, at a minimum, patient histories; x-rays (if taken); examination results; test results; record of drugs prescribed, dispensed or administered; results of consultation or referrals; IDENTIFICATION OF ALL TREATMENTS PERFORMED AND WHEN THEY WERE PERFORMED; and copies of records or reports or other documentation obtained from healthcare practitioners at the request of the dentist and relied upon by the dentist in determining the appropriate treatment of the patient.
Dental software programs allow for quick documentation of routine procedures. Additional comments to the patient record by the staff/dentist and thorough review by the practitioner add insight to the treatment rationale and subsequent quicker claims payment.
Consider updating the templates in your office software and how the patient records are reviewed.