Dental Office Records Management and HIPAA Compliance

Elsevier items and derived items Copyright © 2016, 2011 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Working with Dental
Office Documents
Chapter 7
1

Management and Recordkeeping
1. Define the key terms in this chapter.
2. Discuss the records management system in a dental
office and identify the various categories of records
that are maintained in a dental office.
3. Discuss HIPAA and how to implement HIPAA
regulations in the dental office record management
system.
Lesson 7.1
2

Records Management System
 A record is data in forms such as text,
numbers, images, or voice that is kept for
future reference
 Records management system refers to a set
of procedures used to organize, store,
retrieve, remove, and dispose of records
3

Records Management System
4

Categories of Records
 Vital records
 Patient clinical and financial records
 Office’s corporate charter, mortgage, deed, and
other such records
 Important records
 Accounts payable and receivable
 Invoices, canceled checks, inventory, payroll
records, and other federal records
5

Categories of Records
 Useful records
 Bank reconciliations, petty cash vouchers, expired
insurance policies
 This category can vary according to the office
definition
 Nonessential records
 Reminder notes, outdated announcements,
pamphlets, or flyers
6

Health Insurance Portability and
Accountability Act (HIPAA)
 HIPAA affects the dental business office in a
number of ways
 The purpose of HIPAA is to protect and
enhance patients’ rights
 HIPAA provisions require national standards
for electronic healthcare transactions
7

HIPAA
 Protected patient health information is
anything that ties a patient’s name or Social
Security number to that person’s health,
healthcare, or payment for healthcare, such
as radiographs, charts, or invoices
8

HIPAA
 The American Dental Association (ADA) and
most state dental associations provide the
necessary tools for implementation of HIPAA
standards and regulations
9

HIPAA:
Notice of Privacy Practices
10
Courtesy Patterson Office Supplies, Champaign, Illinois.

HIPAA:
Business Associate Contract Terms
11

Importance of Complete
and Accurate Records
4. Discuss the importance of maintaining accurate clinical
records, including:
• List the components of a clinical record.
• Discuss the purpose of certified electronic health records (EHR).
• Explain the rules for entering data into patient records.
• Discuss the various types of clinical data entries.
• Explain the use of symbols and abbreviations in clinical records.
• Describe the methods of records retention and transfer.
5. Identify various types of records required by the Occupational
Safety and Health Administration (OSHA) that must be
maintained in a dental office.
6. Identify the various types of employee records.
Lesson 7.2
12

Clinical Records
 Components of all the treatment processes
are included in this record
 Updating and maintaining the clinical record
is the administrative assistant’s responsibility
 Accurate clinical records are vital
13

Clinical Records:
Components of a Clinical Record
 The dentist chooses the components and
mode of the clinical record
 Most offices use computerized systems for at
least part of the administrative process but
keep paper documents for some data
14

Clinical Records:
Electronic Health Records (EHR)
 The ultimate goal of the EHR system is to
enable the sharing of health information
among authorized providers across multiple
healthcare settings
15

Patient File Envelope or Folder
16

Clinical Records:
Patient File Envelope or Folder
 A file envelope or folder guards against
misplacement of patient records
 Color-coding is necessary to make sorting,
storing, and retrieval easier
17

Clinical Records: Patient Registration
and Health History Forms
 Patient registration form
 Contains address, telephone numbers, and e-mail,
in addition to employment and insurance
information
 Correct information is needed for credit checks
 Incomplete information can complicate account
collection later
18

Patient Registration Form
19

 A health history form contains a patient’s
medical information
 An accurate, complete health history is a
preventive measure in patient treatment and a
defense in malpractice suits
 A parent or legal guardian must complete the
health history for a child
 A verbal health history can be given if the patient
is unable to read, but it must be obtained in a
private setting
20

Health History Form
21
Courtesy American Dental Association, Chicago, Illinois.

 A health history update form should be
completed periodically to keep both the
health history and the personal information
current
22

Health History Update Form
23

 When you collect patient information:
 Provide a comfortable, relatively private location
 Ask the patient to arrive 15 minutes early to
complete the initial form
 Place the form on a clipboard and provide a pen
 Do not ask questions in a public area of the office
 Make certain a parent or legal guardian completes
the form for a child
 Keep the information absolutely confidential
 Review the form for completeness and signature
24

Clinical Records:
Client Chart
 Dental charts are available in a wide
selection, but all charts have common
components, including patient identification, a
tooth chart diagram, and an area for clinical
notes
 Most supply companies can custom design a
clinical chart for the dentist
25

Clinical Chart Form
26

 The reverse side of the clinical chart or a
separate form may be used for entering the
services rendered, fees, and progress notes
 The administrative assistant enters the date,
services, and fees in the patient’s financial
record where payments and balances are
maintained
27
Clinical Records:
Treatment Record/Progress Notes

Clinical Records: Dental Diagnosis,
Treatment Plan, and Estimate
 The Dental Diagnosis, Treatment Plan, and
Estimate form contains the dentist’s
diagnosis, the recommended treatment plan,
and various other treatment options to be
presented to the patient
 Once the patient has accepted the treatment
plan, the person responsible for the account
signs the form
28

Dental Diagnosis, Treatment
Plan, and Estimate
29

Clinical Records:
Consultation and Referral Report
 The Consultation and Referral Report is used
when the patient is referred to another dentist
for examination, evaluation, and/or diagnosis
 The dentist can use a preprinted form or write
a letter that includes:
 Information about the patient
 The reason for referral
 The anticipated treatment plan
30

Consultation and Referral Report
31

Clinical Records: Medications
History and Prescriptions
 Obtaining a history and current list of all
medications taken by a patient helps prevent
the prescription of drugs that could lead to
unsafe interactions or negatively affect a
chronic health condition
 List the dates and nature of each prescription
32

Medications History
and Prescriptions
33

Clinical Records:
Laboratory Requisitions
 A prescription for dental work to the dental
laboratory
 Requisition specifies the materials and methods
used to create prosthetic dental devices
 States determine use of such a form, if required
34

Laboratory Requisition Form
35

Clinical Records:
Consent Form
 The consent form serves as a record that the
patient has had the opportunity to ask
questions about the benefits and risks of a
proposed treatment and is making an
informed decision about his or her care
36

Consent Form
37

Clinical Records:
Refusal of Treatment
 When a patient refuses to have a
recommended treatment, the dentist should
have the patient sign a refusal of treatment
form
38

Refusal of Treatment Form
39

Clinical Records:
Additional Components
 Letters
 Postal receipts
 Radiographic films
 Test results
40

Clinical Records: Entering
Data on a Clinical Chart
 All data entered in a patient’s clinical chart or
progress notes should be:
 Dated
 Accurate and complete
 Initialed by the treating dentist and assistant
 Failure to document any activity completely
and accurately may prove costly in a lawsuit
41

Clinical Records: Types of
Clinical Data Entries
 Entering information in the patient’s clinical
chart or progress notes involves the use of
tooth numbering systems and an assortment
of abbreviations and symbols
42

Types of Clinical Data Entries:
Tooth Nomenclature
 Primary dentition: 20 teeth (A to T)
 Permanent dentition: 32 teeth (1 to 32)
 Mixed dentition: Some primary and some
permanent teeth
 Correct tooth identification sequence
 Dentition, arch, quadrant, specific tooth
43

Tooth Numbering Systems
 The objective of a numbering system is to
identify each tooth numerically or
alphabetically
 The most common numbering systems are:
 Universal Numbering System
 Palmer Notation System
 Fédération Dentaire Internationale (FDI) system
44

Universal Numbering System
45

Palmer Notation System
46

FDI System
47

Tooth Surfaces
48

Charting Symbols and Abbreviations
49

Clinical Records:
Records Retention
 Records must be retained in the office for the
period of time set by the statute of limitations
in the state
 The statute of limitations is the period within which
a civil suit for alleged wrongdoing may be legally
filed
 This period varies from state to state
50

Clinical Records:
Records Transfer
 A records transfer requires the patient’s
consent, and only information for which
consent is given may be transferred
 The dental record is never changed before
transfer
 The office keeps the original records
 A reasonable clerical fee may be charged for
furnishing the records, in accordance with
local standards
51

Occupational Safety and Health
Administration (OSHA) Records
 OSHA records relating to each employee:
 Medical records
 Copies of employee hepatitis B vaccination
records or hepatitis B vaccination declination form
 Exposure incident forms
 Follow-up documents on exposure incidents
 OSHA training documentation
52

Employee Records
 Several employee records must be
maintained, accurately and confidentially, in
the office
 Employee’s application for employment
 Employment agreements and contracts
 Merit evaluation forms
 Health and medical forms
 Federal Employment Eligibility Verification forms
 Employee records are classified as:
 Employment forms
 Employment Tax Information forms
53

Questions?
54

Dental Office Records Management and HIPAA Compliance

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