Record-keeping

Purpose

The American Academy of Pediatric Dentistry (AAPD) recognizes the patient record is an essential component of the delivery of competent and quality oral health care. It serves as an information source for the care provider and patient, as well as any authorized third party. This document will assist the practitioner in assimilating and maintaining a comprehensive, uniform, and organized record addressing patient care. However, it is not intended to create a standard of care. 

Methods

This best practice was developed by the Council on Clinical Affairs and adopted in 2004. This document is a revision of the previous version, last revised in 2012. This revision included a new literature search of the PubMed®/MEDLINE database using the terms: dental record, electronic patient record, problem-oriented dental record, medical history taking, medical record, record keeping, and Health Insurance Portability and Accountability Act (HIPAA); fields: all; limits: within the last 10 years, humans, and English. Papers for review were chosen from this list and from the references within selected articles and dental textbooks. When data did not appear sufficient or were inconclusive, recommendations were based upon expert and/or consensus opinion by experienced researchers and clinicians. 

Background

The patient record provides all privileged parties with the history and details of patient assessment and communications between dentist and patient, as well as specific treatment recommendations, alternatives, risks, and care provided. The patient record is an important legal document in third party relationships. Poor or inadequate documentation of patient care consistently is reported as a major contributing factor in unfavorable legal judgments against dentists.1  Therefore, the AAPD recognizes that recommendation on record-keeping may provide dentists the information needed to compile an accurate and complete patient chart that can be interpreted by a knowledgeable third-party.

An electronic patient record is becoming more commonplace, and perhaps will become mandatory.1-3  Health information systems and electronic health records are being implemented as a means to improve the quality and efficiency of health care.4  Advantages include quality assurance by allowing comparative analysis of groups of patients or providers, medical and dental history profiles for demographic data, support for decision making based on signs and symptoms, administrative management for patient education and recall, and electronic data interchange with other professional and third parties. The software must contain all the essential elements of a traditional paper record. Daily back up of the office software system should be performed and stored in an electronic data base that is retrievable by office personnel in the event that patient records are lost or damaged.

The elements of record-keeping addressed in this document are general charting considerations; initial patient record; components of a patient record; patient medical and dental histories; comprehensive and limited clinical examinations; treatment planning and informed consent; progress notes; correspondence, consultations, and ancillary documents; and confidential notes. Additionally, appendices to this guideline illustrate items for consideration in the development of patient medical and dental histories and examination forms. These lists, developed by experts in pediatric dentistry and offered to facilitate excellence in practice, should be modified as needed by individual practitioners. These samples do not establish a standard of care. In issuing this information, the AAPD is not engaged in rendering legal or other professional advice. If such services are required, competent legal or other professional counsel should be sought.

Recommendations

General charting considerations
The dental record must be authentic, accurate, legible, and objective. Each patient should have an individual dental record. Chart entries should contain the initials or name of the individual making the note. Abbreviations should be standardized for the practice. After data collection, a list is compiled that includes medical considerations, psychological/ behavior constraints, and the oral health needs to be addressed. Problems are listed in order of importance in a standardized fashion making it less likely that an area might be overlooked. The plan identifies a general course of treatment for each problem. This plan can result in the need for additional information, consultation with other practitioners, patient education, and preventive strategies.

Initial patient record
The parent’s/patient’s initial contact with the dental practice, usually via telephone, allows both parties an opportunity to address the patient’s primary oral health needs and to confirm the appropriateness of scheduling an appointment with that particular practitioner. During this conversation, the receptionist may record basic patient information such as:

  • patient’s name, nickname, and date of birth.
  • name, address, and telephone number of parent.
  • name of referring party. 
  • significant medical history.
  • chief complaint.
  • availability of medical/dental records (including radiographs) pertaining to patient’s condition.

Such information constitutes the initial dental record. At the first visit to the dental office, additional information would be obtained and a permanent dental record developed.

Components of a patient record
The dental record must include each of the following specific components:

  • medical history.
  • dental history.
  • clinical assessment. 
  • diagnosis.
  • treatment recommendations.
  • progress notes. 
  • acknowledgment of receipt of Notice of Privacy Practices/HIPAA consent.5,6

When applicable, the following should be incorporated into the patient’s record as well:

  • radiographic assessment.
  • caries risk assessment.
  • parental consent/patient assent. 
  • sedation/general anesthesia records.
  • trauma records.
  • orthodontic records.
  • consultations/referrals.
  • laboratory orders.
  • test results. 
  • additional ancillary records.

Medical history7-10
An accurate, comprehensive, and up-to-date medical history is necessary for correct diagnosis and effective treatment planning. Familiarity with the patient’s medical history is essential to decreasing the risk of aggravating a medical condition while rendering dental care. Additionally, a thorough history can aid the diagnosis of dental as well as medical conditions. The practitioner, or staff under the supervision of the practitioner, must obtain a medical history from the parent (if the patient is under the age of 18) before commencing patient care. When the parent cannot provide adequate details regarding a patient’s medical history, or if the dentist providing care is unfamiliar with the patient’s medical diagnosis, consultation with the medical health care provider may be indicated.

Documentation of the patient’s medical history includes the following elements of information, with elaboration of positive findings: 

  • medical conditions and/or illnesses.
  • name and, if available, telephone number of primary and specialty medical care providers.
  • current therapies (e.g., physical, occupational, speech) 
  • hospitalizations/surgeries.
  • anesthetic experiences. 
  • current medications. 
  • allergies/reactions to medications.
  • other allergies/sensitivities.
  • immunization status.
  • review of systems. 
  • family history.
  • social history.

Appendix I provides suggestions for specific information that may be included in the written medical questionnaire or during discussions with the patient/parent. The history form should provide the parent/legal guardian additional space for information regarding positive historical findings, as well any medical conditions not listed. There should be areas on the form indicating the date of completion, the signature of the person providing the history (along with his/her relationship to the patient), and the signature of the staff member reviewing the history with the parent/legal guardian. Records of patients with significant medical conditions should be marked Medical Alert in a conspicuous yet confidential manner.

Supplemental history for infants/toddlers11,12
The very young patient can present with unique developmental and social concerns that impact the health status of the oral cavity. Information regarding these considerations may be collected via a supplemental history questionnaire for infants/toddlers. Topics to be discussed may include a history of prematurity/perinatal complications, developmental considerations, feeding and dietary practices, timing of first tooth appearance, and tooth brushing initiation and timing as well as toothpaste use. Assessment of developmental milestones (e.g., gross/fine motor skills, language, social interactions) is crucial for early recognition of potential delays and appropriate referral to therapeutic services.13  As a majority of infants and toddlers of employed mothers receive childcare on a regular basis from persons other than their parents,14 and because the primary caretaker influences the child’s risk for caries, the questionnaire also should ascertain childcare arrangements. Data gathered from this questionnaire will benefit the clinical examination, caries risk assessment, preventive homecare plan, and anticipatory guidance counseling. A sample form is available on the AAPD website at http://www.aapd.org/media/ Policies_Guidelines/RS_MedHistoryForm.pdf.

Supplemental history for adolescents10,12
The adolescent can present particular psychosocial characteristics that impact the health status of the oral cavity, care seeking, and compliance. Integrating positive youth development8 into the practice, the practitioner should obtain additional information confidentially from teenagers. Topics to be discussed may include nutritional and dietary considerations, eating disorders, alcohol and substance abuse, tobacco usage, over-the-counter medications and supplements, and body art (e.g., intra- and extra-oral piercings, tattoos), as well as the use of oral contraceptives and pregnancy for the female adolescent. A sample confidential history form is available on AAPD’s website at http://www.aapd.org/media/Policies_Guidelines/RS_ MedHistoryForm.pdf.

Medical update12
At each patient visit, the history should be consulted and updated. Recent medical attention for illness or injury, newly diagnosed medical conditions, and changes in medications should be documented. A written update should be obtained at each recall visit.

Dental history8,9,11,15
A thorough dental history is essential to guide the practitioner’s clinical assessment, make an accurate diagnosis, and develop a comprehensive preventive and therapeutic program for each patient. The dental history should address the following:

  • chief complaint. 
  • previous dental experience. 
  • date of last dental visit/radiographs.
  • oral hygiene practices. 
  • fluoride use/exposure history.
  • dietary habits (including bottle/no-spill training cup use in young children). 
  • oral habits.
  • sports activities.
  • previous orofacial trauma.
  • temporomandibular joint (TMJ) history.
  • family history of caries.
  • social development.

Appendix II provides suggestions for specific information that may be included in the written dental questionnaire or during discussions with the patient/parent.

Comprehensive clinical examination7,8,16
The clinical examination is tailored to the patient’s chief complaint (e.g., initial visit to establish a dental home, acute traumatic injury, second opinion). A visual examination should precede other diagnostic procedures. Components of a comprehensive oral examination include:

  • general health/growth assessment/body mass index calculation (e.g., height, weight, vital signs).
  • pain assessment.
  • extraoral soft tissue examination.
  • TMJ assessment.
  • intraoral soft tissue examination. 
  • oral hygiene and periodontal health assessment.
  • assessment of the developing occlusion. 
  • intraoral hard tissue examination. 
  • radiographic assessment, if indicated.17 
  • caries risk assessment.18 
  • assessed behavior of child.19

Appendix III provides suggestions for specific information that may be included in the oral examination.

The dentist may employ additional diagnostic tools to complete the oral health assessment. Such diagnostic aids may include electric or thermal pulp testing, photographs, laboratory tests, and study casts. The speech may be evaluated and provide additional diagnostic information in children who are able to talk.

Examinations of a limited nature
If a patient is seen for limited care, a consultation, an emergency, or a second opinion, a medical and dental history must be obtained, along with a hard and soft tissue examination as deemed necessary by the practitioner. The parent should be informed of the limited nature of the treatment and counseled to seek routine comprehensive care. The AAPD’s Assessment of Acute Traumatic Injuries form20 provides greater details on diagnostic procedures and documentation for emergent traumatic injury care.

Treatment recommendations and informed consent21
Once the clinician has obtained the medical and dental histories and evaluated the facts obtained during the diagnostic procedures, the diagnoses should be derived and a sequential prioritized treatment plan developed. The treatment plan would include specific information regarding the nature of the procedures/materials to be used, number of appointments/ time frame needed to accomplish this care, behavior guidance techniques, and fee for proposed procedures. The dentist is obligated to educate the parent on the need for and benefits of the recommended care, as well as risks, alternatives, and expectations if no intervention is provided. When deemed appropriate, the patient should be included in these discussions. The dentist should not attempt to decide what the parent will accept or can afford. After the treatment plan is presented, the parent should have the opportunity to ask questions regarding the proposed care and have concerns satisfied prior to giving informed consent. For adult patients with special health care needs, it is important to determine who legally can provide consent for treatment.21  The practitioner should document interpreters or translation services used to aid communication (e.g., in person, by telephone). Documentation should include that the parent appeared to understand and accepted the proposed procedures. Any special restrictions of the parent should be documented.

Progress notes
An entry must be made in the patient’s record that accurately and objectively summarizes each visit. The entry must minimally contain the following information:

  • date of visit.
  • reason for visit/chief complaint. 
  • radiographic exposures and interpretation, if any. 
  • treatment rendered including, but not limited to, the type and dosage of anesthetic agents22, medications, and/or nitrous oxide/oxygen23, type/duration of pro- tective stabilization24, treatment complications, and adverse outcomes.
  • post-operative instructions and prescriptions as needed.

In addition, the entry generally should document:

  • changes in the medical history, if any.
  • adult accompanying child.
  • verification of compliance with preoperative instructions.
  • reference to supplemental documents.
  • patient behavior guidance.
  • planned treatment for next visit.

A standardized format may provide the practitioner a way to record the essential aspects of care on a consistent basis. One example of documentation is the SOAP note.25 SOAP is an acronym for subjective (S) or the patient’s response and feeling to treatment, objective (O) or the observations of the clinician, assessment (A) or diagnosis of the problem, and procedures accomplished and plans (P) for subsequent problem resolving activities. The signature or initials of the office staff member documenting the visit should be entered.

When sedation or general anesthesia is employed, additional documentation on a time-based record is required, as discussed in the AAPD’s Guideline for Monitoring and Management of Pediatric Patients Before, During and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016.26

Progress notes also should include telephone conversations regarding the patient’s care, appointment history (i.e., cancellations, failures, tardiness), non-compliance with treatment recommendations, and educational materials utilized (both video and written), along with identification of the staff member making the entry in the dental record.

Orthodontic treatment
The AAPD’s Recommendation on Management of the Developing Dentition and Occlusion in Pediatric Dentistry27 provides general recommendations on the documentation of orthodontic care. Signs and/or symptoms of TMJ disorders should be recorded when they occur before, during, or after orthodontic treatment.28  During orthodontic treatment, progress notes should include deficiencies in oral hygiene, loose bands and brackets, patient complaints, caries, root resorption, and cancellations and failures.

Correspondence, consultations, and ancillary documents
The primary care dentist often consults with other health care providers in the course of delivery of comprehensive oral health care, especially for patients with special health care needs or complex oral conditions. Communications with medical care providers or dental specialists should be incorporated into the dental record. Written referrals to other care providers should include the specific nature of the referral, as well as pertinent patient history and clinical findings. Reports received from other health care providers should be incorporated into the patient’s chart. A progress note should be made on correspondence sent or received regarding a referral, indicating documentation filed elsewhere in the patient’s chart. Copies of test results, prescriptions, laboratory work orders, and other ancillary documents should be maintained as part of the dental record.

Appendices*

* The information included in the following samples, developed by the AAPD, is provided as a tool for pediatric dentists and other dentists treating children. It was developed by experts in pediatric dentistry and is offered to facilitate excellence in practice. However, these samples do not establish a standard of care. In issuing this information, the AAPD is not engaged in rendering legal or other professional advice. If such services are required, competent legal or other professional counsel should be sought.

Appendix I—Medical history*
Name and nickname
Date of birth
Gender
Race/ethnicity
Name, address, and telephone number of all physicians
Date of last physical examination
Immunization status
Summary of health problems
Any health conditions that necessitate antibiotics or other medications prior to dental treatment
     Allergies/sensitivities/reactions
     Anesthetics, local and general
     Sedative agents
     Drug or medications
     Environmental (including latex, food, dyes, metal, acrylic)
Medications (including over-the-counter medications, vitamins, and homeopathic and herbal supplements) — dose, frequency, reactions
Hospitalizations—reason, date, and outcome
Surgeries—reason, date, and outcome
Significant injuries—description, date, and outcome
General
     Complications during pregnancy and/or birth
     Prematurity
     Congenital anomalies
     Cleft lip/palate
     Inherited disorders
     Nutritional deficiencies
     Problems of growth or stature
Head, ears, eyes, nose, throat
     Lesions in/around mouth
     Chronic adenoid/tonsil infections
     Chronic ear infections
     Ear problems
     Hearing impairments
     Eye problems
     Visual impairments
     Sinusitis
     Speech impairments
     Apnea/snoring
     Mouth breathing
Cardiovascular
     Congenital heart defect/disease
     Heart murmur
     Infective endocarditis
     High blood pressure
     Rheumatic fever
     Rheumatic heart disease
Respiratory
     Asthma—medications, triggers, last attack, hospitalizations
     Tuberculosis
     Cystic fibrosis
     Frequent colds/coughs
     Respiratory syncytial virus
     Reactive airway disease/breathing problems
     Smoking
Gastrointestinal
     Eating disorder (e.g., anorexia, bulimia, pica)
     Ulcer
     Excessive gagging
     Gastroesophageal/acid reflux disease
     Hepatitis
     Jaundice
     Liver disease
     Intestinal problems
     Prolonged diarrhea
     Unintentional weight loss
     Lactose intolerance
     Dietary restrictions
Genitourinary
     Bladder infections
     Kidney infections
     Pregnancy
     Systemic birth control
     Sexually transmitted infections
Musculoskeletal
     Arthritis
     Scoliosis
     Bone/joint problems
     Temporomandibular disorders (TMD)—joint popping, clicking, locking, difficulties opening or chewing
Integumentary
     Herpetic/ulcerative lesions
     Eczema
     Rash/hives
     Dermatologic conditions
Neurologic
     Fainting
     Dizziness
     Autism spectrum disorder
     Developmental disorders
     Learning problems/delays (e.g., enrollment in specialized school or individualized education plan)
     Mental disability
     Brain injury
     Cerebral palsy
     Convulsions/seizures
     Epilepsy
     Headaches/migraines
     Hydrocephaly
     Shunts—ventriculoperitoneal, ventriculoatrial, ventriculovenous
Psychiatric
     Maltreatment (e.g., physical abuse, sexual abuse, dental neglect, bullying)
     Alcohol and chemical dependency
     Emotional disturbance
     Hyperactivity/attention deficit hyperactivity disorder
     Pediatric acute-onset neuropsychiatric syndrome (PANS)
     Obsessive compulsive disorder
     Psychiatric problems/treatments or medications
Endocrine
     Diabetes
     Growth delays
     Hormonal problems
     Precocious puberty
     Thyroid problems
Hematologic/lymphatic/immunologic
      Anemia
      Blood disorder
      Transfusion
      Excessive bleeding
      Bruising easily
      Hemophilia
      Sickle cell disease/trait
      Cancer, tumor, other malignancy
      Immune disorder
      Chemotherapy
      Radiation therapy
      Hematopoietic cell (bone marrow) transplant
Infectious
      Measles
      Mumps
      Rubella
      Scarlet fever
      Varicella (chicken pox)
      Mononucleosis
      Cytomegalovirus (CMV)
      Pertussis (whooping cough)
      Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS)
      Sexually transmitted infections
      Lyme disease
       Zika virus
Family history
       Genetic disorders
       Problems with general anesthesia
       Serious medical conditions or illnesses
Social concerns
       Chronic passive smoke exposure
       Religious or philosophical objections to treatment
       Legal custody/guardianship status


Appendix II—Dental History*
Previous dentist, address, telephone number
Date of last dental examination
Date of last dental radiographs, number and type taken, if known
Date of last fluoride treatment
Prenatal/natal history
Family history of caries, including parents and siblings
History of smoking in the home
Medications or disorders that would impair salivary flow
Injuries to teeth and jaws, including TMJ trauma
       When/where/how
       Treatment required
Dental pain and infections
Habits (past and present) such as finger, thumb, pacifier, tongue or lip sucking, bruxism, clenching
Snoring
Diet and dietary habits
       Breast-feeding—frequency, weaned/when
       Bottle feeding/no-spill training (sippy) cup use
       Frequency
       Content—Formula, milk water, juice
       Weaned/when
       Sugar-sweetened or sugar-containing beverages (e.g., sodas, fruit juice, sports drinks)—amount, frequency
       Snacks—type, frequency
       Meals—balanced, frequency, restricted or special diet
Oral hygiene
       Frequency of brushing, flossing, oral rinse use
       Assisted/supervised
Fluoride exposure
       Primary source of drinking water—home, daycare, other
       Water—tap, bottled, well, filtered/reverse osmosis
       Systemic supplementation—tablets, drops
       Topical—toothpaste, rinses, prescription
Previous orthodontic treatment
Behavior of child during past dental treatment
Behavior anticipated for future treatment


Appendix III—Clinical Examination*

General health/growth assessment
       Growth appropriate for age
       Height/weight/frame size/body mass index (BMI)
       Vital signs—pulse, blood pressure
Extraoral examination
        Facial features
        Nasal breathing
        Lip posture
        Symmetry
        Pathologies
        Skin health
TMJ/TMD16
        Signs of clenching/bruxism
        Headaches from TMD
        Pain
        Joint sounds
        Limitations or disturbance of movement or function
Intra-oral soft tissue examination
        Tongue
        Roof of mouth
        Frenulae
        Floor of mouth
        Tonsils/pharynx
        Lips
        Pathologies noted
Oral hygiene and periodontal assessment29,30
        Oral hygiene, including an index or score
        Gingival health, including an index or score
        Probing of pocket depth, when indicated
        Marginal discrepancies
        Calculus
        Bone level discrepancies that are pathologic
        Recession/inadequate attached gingiva
        Mobility
        Bleeding/suppuration
        Furcation involvement
Assessment of the developing occlusion
        Facial profile
        Canine relationships
        Molar relationships
        Overjet
        Overbite
        Midline
        Crossbite
        Alignment
        Spacing/crowding
        Centric relation/centric occlusion discrepancy
        Influence of oral habits
        Appliances present
Intraoral hard tissue examination
        Teeth present
        Supernumerary/missing teeth
        Dental development status
        Over-retained primary teeth
        Ankylosed teeth
        Ectopic eruption
        Anomalies/pathologies noted
       Tooth size, shape discrepancies
       Tooth discoloration
       Enamel hypoplasia/fluorosis
       Congenital defects
       Existing restorations
       Defective restorations
       Caries
       Pulpal pathology31,32
       Traumatic injuries
        Third molars
Radiographic examination33
        Developmental anomalies
        Eruptive patterns/tooth positions/root resorption
        Crestal alveolar bone level
        Pulpal/furcation/periapical pathology
        Caries—presence, proximity to pulp space, demineralization/remineralization
        Existing pulpal therapy/restorations
        Traumatic injury
        Calculus deposits
        Occult disease
        Explanation of inability to obtain diagnostic image when indicated
Caries-risk assessment

References

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