Patient Safety in Dentistry: Documentation

The following article is the second installment in a three-part series on patient safety in dentistry. Part 1, “Patient Communication,” appeared in the December issue of Florida Focus. Part 3, “Managing Adverse Events,” appeared in the March 2022 issue.

The relationship between patient safety and documentation may seem remote at first. Patient safety strategies are designed to reduce the risk of adverse events, dental error, and patient harm. Understanding the risks posed by incomplete, inappropriate, or inadequate documentation requires consideration of how a dental record functions. The primary purpose of clinical documentation is to create an orderly chronological record of the clinical decision-making process, treatment provided, and patient responses. Subsequent treating providers rely on the information contained in the record to inform their clinical judgment and treatment. Records that are incomplete or inaccurate may lead to inappropriate treatment and patient harm. Consider the following example.

A 24-year-old female patient was referred to a periodontist by her general dentist. The referral form and dental record both stated that the patient had no known medication allergies (NKDA). Periodontal staff created a medical record for the patient and populated the history and medication fields based on information provided in the records sent by the general dentist’s office. On the day of surgery, the periodontist examined the patient and confirmed the finding of a deep pocket requiring surgical intervention. The surgery went well, and the patient left with postoperative instructions and a prescription for antibiotics.

The following day, the periodontal practice learned that the patient had suffered a severe anaphylactic reaction to the antibiotic. The patient had a preexisting allergy to the antibiotic prescribed. She subsequently filed a malpractice complaint against the general dentist and periodontist. Expert witness statements were critical of the general dentist and periodontist for failing to reconcile medications and allergies.

In the example above, the general dental practice sent inaccurate records to the specialist. Staff members at the periodontal practice had preloaded the clinical information provided by the general dentist into their dental record system. The patient did not review the prior history and medication list and was not asked to confirm the information included in the periodontal practice’s record.

Claims Analysis and Documentation Requirements

While it is difficult to determine how often poor documentation directly affects patient care, closed malpractice claim analysis provides insights into patient harm events in which documentation may have played a role. The Doctors Company reviewed 1185 dental claims that closed between 2010 and 2020. Documentation issues, the fifth-leading causal factor identified by analysts, appeared in 19 percent of claims. Insufficient documentation was the leading causal factor, followed by content decisions and documentation mechanics. See Table 1 for the top three sources of insufficient documentation. Content decisions generally involved bad decisions that affected defensibility, such as altering the record. Documentation mechanics (process errors) included documenting the wrong chart, transcription errors, and delays. Analysts found a direct correlation between poor documentation and adverse events in 14 claims.

Before delving deeper into insufficient documentation, it is essential to consider what is required. Dentistry is one of the many professions regulated at the state level. Record management requirements are typically defined by statute and further specified in rules. Organizations may also define documentation expectations in policies, procedures, and workflows. Dental professionals should be aware that, during legal and regulatory investigations, courts and professional boards may also consider compliance with policies and procedures. According to Florida Rule 64B5-17.002(1), “the dental record shall contain sufficient information to 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;
• examination results;
• test results;
• records of drugs prescribed, dispensed, or administered;
• reports of consultation or referrals; and
• copies of records or reports or other documentation obtained from health care practitioners at the request of the dentist and relied upon by the dentist in determining the appropriate treatment of the patient.”

The regulatory list is helpful as a high-level guide and checklist for assessing compliance. From a patient safety perspective, the elements require some expounding. For example, patient history should include past dental history, pertinent medical history (cancer, diabetes, cardiovascular disease, immunosuppression), pertinent family history (cancer), social history (smoking, alcohol consumption, barriers to care), and history of the present complaint.

Histories are critical to reducing the risk of delay in diagnosis. Historical risk factors may trigger more frequent and more targeted oral assessments. In addition to including the medications used and prescribed by the dental practice, the dental record should contain information about the patient’s allergies and pertinent chronic medications. Question patients directly about their use of medications known to affect dental decision making, such as bisphosphonates,¹ anticoagulants,² hypoglycemics,³ oral bupenorphine,⁴ and opioids. (Note the ADA 2016 statement on opioid use in dentistry recommends that dentists follow state and CDC opioid guidelines.)

Document the dental record with referral communications and include copies of referral documents sent and received. Document all clinical communications with patients and families. Use the telephone notes section of the electronic dental record (EDR), if available, or identify a suitable alternative within the record. The content of clinical communications that occur outside of an office visit may be as essential to the clinical picture as the visit note. Include a summary of the concern, questions asked and answered, and recommendations. Front desk staff should not provide clinical advice unless they have proof of education, training, and competence. Because dentists are responsible for the documentation of their unlicensed assistants, ensure that the information provided is accurate and complete by reviewing their notes periodically. If the patient communicates by email or text, incorporate the actual exchange into the record by printing and scanning.

Electronic Dental Records

EDRs have streamlined some office functions, such as scheduling, billing, and storing patient information. They also, however, present a number of documentation and patient safety risks. Dental record documentation should tell the story of the patient’s care. It is much harder to get the story across in a template. When using an EDR, do not limit documentation to simply checking boxes. Every patient record should be personalized to the patient in some way. Often the record contains a free text note function for providers to document patient-specific information. Patients may be harmed when outdated information is pulled forward or copied and pasted and then relied on for current treatment. Ideally, copy and paste should not be used at all. Information should never be copied from one record to another.

EDR software tracks and logs documentation activities using descriptive information called metadata. Metadata exists in the memory behind what users can see on the screen. It typically includes information about who made the entry, when information was entered, and the length of time the record was open. Some electronic records also capture where clinical data originated—its provenance. A provenance audit can identify the original author and the location of copied and pasted material. Like information stored in other formats, metadata and provenance audits are discoverable and may be used during regulatory and legal proceedings.

Three Risks Contributing to Patient Harm

Table 1 identified the top three areas of risk created by insufficient or poor documentation: clinical findings, informed consent, and clinical rationales.

Clinical findings are the interpretations that result from a review of histories, oral assessments, diagnostic tests, procedures, and consult recommendations. After the actions associated with a dental examination or procedure are completed and documented, the negative and positive findings (present or absent) must be “appreciated” and included in the record. The review and management of dental radiographic findings are good examples. Both panography and cone beam computed tomography (CBCT) images can result in incidental findings. As dental radiography improves (particularly CBCT resolution), incidental findings become more frequent and diverse. Currently, no standard classification scheme exists for determining the importance of dental radiographic incidental findings.

Failure to note an incidental finding on a radiographic examination is an example of insufficient clinical documentation. The provider who orders and interprets the scan is responsible for the findings, regardless of whether they are directly related to the purpose of the scan. When incidental findings are located in structures that generally fall outside the area of interest (that is, extragnathic), a decision must be made as to whether the finding is benign, can be watched, or requires follow-up. The provider who performed the study owns the results until the findings are managed. It is not safe to ignore or fail to appreciate incidental findings.

A 2019 meta-analysis of CBCT incidental findings identified atherosclerotic calcifications in the carotid arteries (CAC) as a “life threatening” finding.⁵ The frequency of CAC findings varies by study (5.7 percent to 11.6 percent in three studies),⁵ and the risk varies by location (intracranial versus extracranial).⁶ Dentists are cautioned to objectively document in the record the location of the incidental finding, a determination of clinical significance, and a management strategy. Management strategies may be informed by participating in an overread peer review service, selecting images of concern for head and neck radiology review, and collaborating with the patient’s primary medical care provider on appropriate specialty referrals.

The second most frequent insufficient documentation finding was absent or limited informed consent. Informed consent is a process. The first step is a discussion with the patient about the main problem, planned procedure, risks, benefits, and alternatives to the procedure. Step two is providing the patient with an opportunity to ask questions, receive more education, and make an informed decision. Evaluate the patient’s understanding using teach-back, and document the entire discussion in the record. “Consented patient” is not enough. Informed consent is not done to the patient; the process should be patient-centered and collaborative. To that extent, “patient consented” is not sufficient either. Consider the following example:

“Reviewed [intended procedure] with [name]. Discussed risks, benefits, and alternatives. Provided [educational] handout. Patient was able to accurately summarize the discussion, signed consent, and agreed to proceed.”

Always document the informed consent discussion in a progress note and use a form when necessary. Florida has formalized requirements in the Florida Medical Consent Law (F.S. 766.103).

Tips to avoid informed consent pitfalls:

• Be honest about the likelihood of success. Discuss color matching, the need for adjustments, and the longevity of the work. Do not overpromise.
• Make sure the patient fully understands the risks. Translate consent forms into the major languages spoken by your patient population, and use an interpreter when needed. Do not use family members to interpret.
• Ensure that the likely risks are included in the discussion. In addition to pain and bleeding (as appropriate), include fractured teeth, migrating root tips, and equipment problems, such as fractured wire or burr. When discussing an unlisted risk, note it on the consent form or the informed consent procedure note.
• Use informed consent for dental sedation and anesthesia. Consent forms do not have to be limited to surgical procedures. Consider a form for treatments such as whitening, aggressive hygiene procedures, and ordinary care that presents risks specific to a particular patient.
• Document informed refusal. Patients have the right to refuse treatment. An informed refusal is a useful tool for documenting that the patient accepts the potential risk of refusing treatment.
• Find samples of consent and refusal forms on The Doctors Company’s website at thedoctors.com/sampleconsentforms.

Documentation of clinical rationale is the final area for discussion of the risks created by insufficient documentation. Rationale is sometimes referred to as dental decision making. Documenting decision making is not only good patient safety practice and helpful to downstream dental providers, but it is also often essential to the defense of a board complaint or malpractice claim.

After documenting findings, dental professionals should summarize the findings into a differential diagnosis. Document the final or likely diagnosis and what was considered and ruled out. Establish a mechanism for ensuring that the follow-up occurs if the plan is to recheck something in a specific time frame. Good documentation practices include reviewing the most recent preceding visit and updating any outstanding problems, test results, or referrals. Document the record with all patient requests as well as any decisions made. If a patient request is denied, it is essential to document the clinical reasoning in the record.

Treat the clinical record as a legal document. Make sure the record tells the clinical story. Make sure the record will be a good witness. Ensure the record will represent the practice well if it is shared with patients, families, lawyers, and regulatory agencies. Document well.

See the other articles in this series, “Patient Safety in Dentistry: Communication” and “Patient Safety in Dentistry: Managing Adverse Events in the Practice Setting.”

Reprinted with permission from Florida Focus. March 2022; pages 14–16, Available at https://www.flagd.org/wp-content/uploads/2022/03/Florida-Focus-March-2022-v.5.pdf.