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Dental Records: Best Practices for Information Management and Retention

Course Number: 532

Business Components of the Patient Record

When addressing the issue of the patient record, the business portion focuses on accounts receivables. The financial and clinical records should remain separate. As a patient's financial record is accessed to apply a payment, there is no reason to have protected health information open at the same time.

Dental insurance forms can be created more efficiently by dental software. When the itemized procedures are documented in the patient chart, they can be accessed and printed, saving time for the dental team. These forms are generated with the ADA standardized dental codes and procedure descriptions. This can be forwarded to the dental insurance company for electronic payment or attached to the patient form and mailed for payment processing.

As the patient is billed for services, the family ledger is accessed. As payments are received from the patient or primary/secondary insurance company, they are applied to the balance until paid in full. Until that point, the patient will receive tracked billing statements. If there is any communication regarding payments, this can be added to the correspondence log form.

Another business record involves tracking the patient’s recall/recare due dates. As the time approaches for their appointment, they will be notified of an appointment already set or notified that it is now time to call for an appointment. With the employment of electronic messaging, many dental software services include generated messages that saves time for the administrative assistant. The Telecommunication Consumer Protection Act (TCPA) protects consumers from excessive phone contact or harassment. The patient must authorize use of their personal cell phone for text messages and electronic messages. Voice messages must follow HIPAA guidelines and should be 1 minute or less. Text messages should be less than 160 characters.3 This must be tracked to show that the office is fulfilling the dentist-patient relationship.

Additional business records that affect the patient are in regards to infection control. The OSHA Blood-Borne Pathogens Standard requires biologic monitoring of sterilizers and maintenance of those records.3 While these are not kept directly with patient records, they are supplements kept within the practice. Maintaining the records that prove successful monitoring, training, and waste disposal procedures are supplemental to verifying the dentist’s duty to provide a standard of care. Offices that use off-site biological monitoring in sterilization monitoring will receive written documentation of successful or unsuccessful cycles that must be securely maintained. Those offices that choose to complete biological monitoring in-house will verify reports in a log book. As dental professionals continue mandated training and education in infection control protocols, these course verification certificates will be maintained a binder for easy access as needed or scanned and saved to a program within the dental software program.