Dental Records and Litigation
While most dentists provide exceptional care to their patients, there will be times when a patient is unhappy with the outcome and will pursue legal action. Dentists with inadequate dental records can be particularly vulnerable to a malpractice case, as the attorney overseeing the case will have a difficult time resolving the case with inadequate records. This article will help to outline how to keep adequate patient records.
Why should I keep records?
Not only is it important to keep adequate records to protect oneself from litigation, but it is also important to maintain them for the well-being of the patient. A well-kept dental record shows future dentists an unbiased view of the patients’ health. Maintaining accurate dental records is also helpful if any postmortem identification needs to be made.
What rules and regulations are there?
Some states outline specific requirements for dental records, but more commonly, requirements are found in laws and regulations related to patient care in general, review your State dental practice act, which is usually available online, and consult your state dentistry board for information.
HIPAA Privacy Rule and the Security Rule are important to review when reviewing what and how to keep patient records.
The Privacy Rule includes
- Health information of any form.
While the Security Rule covers:
- Any electronically protected health information that is created, maintained, received or transmitted.
Security Rule demands safeguards in place to:
- Integrity (records are not changed without approval)
- Availability (only authorized people have access to the records)
HIPAA Privacy and Security Omnibus Rule reinforces these rules and extends these guidelines to dental practices’ associates and contractors. If there is a breach of information, the dentist is obligated to inform:
- Media (only in some instances)
What should be kept in a dental record?
The American Dental Association suggests keeping a separate file for financial information, such as invoices, insurance claims, and payment records. The clinical record should include:
- Patient personal information (address, email, etc.)
- Dental history and medications they are currently taking
- HIPAA acknowledgement form, consent forms, privacy forms
- Any oral conditions
- Lab results
- Record of conversations about treatment
- Treatment plan information
- An account of progress with the treatment plan
- Continuity of care
- Documentation if the patient declines treatment, any appointment missed, complaints
Who should have access to records?
It is critical to have a policy in place to outline who should and should not have access to records. This policy should be in line with HIPAA guidelines. Dental records should be kept in a secure location, while electronic records should be protected with passwords that are changed regularly. According to the Security Rule, risk assessment, staff education, and continual use of security safeguards are required.
What should I keep in mind when transferring records?
It is vital to receive permission from the patient before transferring records. Make sure to check your local state laws and HIPAA requirements before transferring information.
- Send as minimal amount of information as necessary
- Only send copies and not originals of records
- Note what information was sent and to whom in the patient’s record
How long should I keep records?
The length of time to keep records is dependent on local state laws and regulations. These regulations will tell you how long to keep records after the patient’s last visit. HIPAA generally requires keeping records for 6 years after the last visit, though it may vary for patients who are children. Some experts do recommend keeping records for upwards of 10 years. It is important to communicate with your staff how long to keep these records, with contractors having in their contracts your records retention policy.
Before converting records to a digital format, it is important to consult your attorney or liability insurer. Off-site physical records are okay, as long as it is secure.
How should I dispose of records?
Make sure to only destroy records that are past the statute of limitations. It is always important to double-check HIPAA regulations as well as state laws before disposing of records.
For paper records, some recommended ways to destroy records are:
For electronic records, HIPAA recommends:
- Destroying the media
Keeping accurate dental records is important
It is important to keep accurate records for a multitude of reasons, such as possible litigation, patient care, and complying with HIPAA and state regulations.
Sources: Judy, Kenneth W. M., and Cynthia Saver. "Quality Records Protect Dentists in Case of Litigation." The National Society of Dental Practitioners and The Dentist’s Advantage Insurance Program for Dentists (2019): n. pag. Print.