I’m always a bit perplexed when I hear someone question the need to build and maintain a comprehensive record for all patients.
To be clear, I insist on it for some very pragmatic reasons.
If a patient complains about your work on a particular problem, it’s good to have records on hand. In most cases, records gathered at the time they became a patient can determine if the problem existed before they began treatment at your practice.
If a patient registers a complaint against a dentist or the dental office, comprehensive records can provide a solid defence in litigation.
A dental record should consist of a Panorex survey, four to seven vertical and/or horizontal bitewings, and, when indicated, a full-mouth series.
When a patient has a history of periodontal disease, a full series of radiographs will be necessary as well as intra- and extraoral photographs. Such photographs should provide: a full face view; a profile view on both right and left sides; a smile view; a view of the upper six to eight front teeth; views of the right and left cuspid; and upper and lower occlusal views.
The record should also contain the worst intraoral condition for the patient (this particular photo should be put into the treatment plan letter for educational and motivational reasons); upper and lower impressions with centric occlusion bite and, if indicated, a centric relation bite; complete and comprehensive periodontal charting; and an overall assessment of the patient’s chief complaint and dental IQ.
Sound like a lot of work? Consider it an ounce of prevention in comparison to the amount of work you’ll need to do if a complaint arises and you have an attorney looking for answers.
I’ve been doing this for 30 years and I’m happy to share my experiences through my dental practice consulting services.