Dental Records Management

Client Records Management

• Records management dictates how client records are handled in a dental practice.
• Client records are also known as client files or charts.
• Professional, ethical, and legal responsibilities require accurate, well-organized, legible, accessible, and understandable client records.
• Client charts gather all relevant information needed for accurate diagnosis and treatment plans.

Client Charts

• Charts must be maintained for each client who has been or is seen in the practice.
• Each chart contains a complete and accurate record of clinical and/or financial activities.
• Client charts are confidential documents filled with subjective and objective data.
• The dental office has a legal and ethical responsibility to handle these records carefully for client care, safety, and protection.

Separation of Clinical and Financial Records

• Clinical-medical history, dental history, updates, and vital signs are included.
• Records for examination areas, radiographs, dental charting, diagnosis and treatment plans, informed consents, and care treatment sheets are included.
• Specialists' letters and referral letters/sheets are examples of additional documents.
• Current X-rays are mounted, while expired X-rays are stored in envelopes.
• Financial fees are service charges for outstanding account balances.

Records Management

• Records are used for ongoing client care, client safety, and office protection.
• Every dental office is legally required to protect, retain, and transfer these documents appropriately.

Federal/Provincial Privacy Acts

• Personal Information Protection and Electronic Documents Act (PIPEDA) is federal.
• Personal Health Information Act (PHIPA) is provincial.
• PIPEDA sets ground rules for private organizations' collection, use, and disclosure of personal information. Individuals have access rights and can request corrections.
• PIPEDA has 10 key principles: accountability, identifying purposes, consent, limiting collection, limiting use, disclosure, and retention, accuracy, safeguards, openness, individual access, and provide recourse.
• PHIPA establishes rules for collecting, using, and disclosing personal health information.
• These acts protect confidentiality while enabling effective healthcare.

Record Protection and Confidentiality

• All client records are confidential and must be protected.
• Never discuss client records with unauthorized individuals.
• If someone calls requesting client record information, obtain consent from the client before releasing any information.
• Dental staff members must know the confidentiality rules for releasing patient information and dental records.
• Records must be securely stored and destroyed at the end of the required retention period. The dental office owns the records, but the information within them belongs to the client.
• Client records must be protected against loss and damage.
• Records need to be kept in locked fireproof cabinets.
• Client charts should be kept out of view of other clients.
• Records must be filed immediately after entries or care.

Records Retention

• Recordkeeping regulations operate under the Dentistry Act 1991.
• Clinical, financial, and drug records need to be maintained for at least 10 years from the last entry date.
• Records for minors need to be kept until the patient turns 18 years of age.
• Records need to be retained for 2 years after the dentist's death.
• Working models don't need to be retained for any specific period; their retention is at the DDS's discretion.
• Diagnostic or study models are part of permanent records and must be kept for 10 years.
• Copies of dental claims must be kept for at least 2 years.
• Electronic copies are also acceptable.

Transferring of Client Records

• When clients move to a new dental office, their records must be transferred.
• The patient's chart is the dentist's property, but the information in it belongs to the patient.
• Obtain written consent from the client before transferring records.
• The original chart is kept by the dental office and a copy is sent to the receiving office.
• Recent radiographs can be duplicated and sent.
• A fee may be charged to cover transfer costs.
• Insurance companies and legal representatives may also request copies of records.

Client Records: Active vs. Inactive

• Active patient charts are those of patients who attend the office for regular care appointments.
• Inactive patient charts are for patients who haven't been to the office for 2-3 years. An attempt has been made to contact these inactive patients; the time frame for recalling a patient varies by dental office.
• Active files are kept in the primary filing system.
• Inactive files are removed and stored in a separate "Inactive" filing area, accessible but not in the main reception area.
• Details of failed appointments, phone calls, letters sent to the client for scheduling, and other notations must be recorded for each patient.

Purging Records

• After 10 years from the last entry, records can be destroyed, unless the record belongs to a minor.
• A purging system is used to go through inactive files.
• Files are then shredded or given to a shredding company, to maintain confidentiality.
• Purging also includes cleaning up active files in the cabinets and replacing damaged folders. Outdated electronic communications should be discarded as well.

Filing Systems

• Alphabetical: Clients are filed by last name, first initial (e.g., Smith, J. Doe, A.).
• Numerical: Patients or accounts are assigned numbers for faster computer retrieval.
• Chronological: Records are filed by date; recent documents are placed in front of older ones within the file folder. This is especially important for treatment records in a patient's clinical chart.
• Cross-References: This uses an alphabetic system alongside another filing method.

Storage

• Vertical and horizontal storage options exist for client records.
• There are a number of ways to organize the office filing system. Often, vertical filing cabinets are used for storing client records. Color-coded folders are used to more easily locate a record belonging to a particular client.

General Filing Rules

• Keep the filing system simple, for best practice, alphabetical and color-coded filing is often the easiest system to use for most practices.
• Have adequate spacing between files. This is important to avoid damaging the files, and to allow ease of movement between files.
• Label shelves and drawers for easier location of files.
• Label file folders clearly with client's full name.
• Use "out-guides" to mark folders that have been removed from a file, akin to a bookmark.

Avoiding Lost Records

• Receptionists must keep track of client records, giving them to treatment staff and then keeping track of any outstanding records that haven't been returned to the filing cupboard when the patient leaves the office.
• Records are sometimes found on the DDS desk, or with the treatment/consultation coordinator, and/or in treatment rooms.
• Staff members must return records immediately following treatment.
• Failure to return a record requires the staff to use the day sheet to follow up and file immediately after usage.

Questions about dental records management including record keeping, storage, and transfer protocols. Covers retention periods for models and claim forms, the use of out-guides, and legal considerations for patient record transfers.