5.3 - Patient Records Policies

The student is granted access to only those patients to which they are assigned. When a patient no longer participates in the program, the student will no longer be provided access to the electronic record.

There are several different record assignments used at the College of Dentistry:  

• Emergency
• Limited Treatment
• Screening
• Dental Hygiene
• Comprehensive Care which includes all assignments for the following clinical courses:  
  • Adult Preventive
  • Patient Contact
  • Clinical Department Care
  • Comprehensive Care

Other areas of record assignments are:

• Faculty Practice
• Advanced Education in General Dentistry
• Graduate Orthodontics Program
• Graduate Periodontics Program

Any student given this type of assignment is granted limited time access only to the record to complete the treatment. 

Treatment History Notes make up the major portion of your required record entries. While documentation of actual clinical interactions with patients is mandatory, all interactions should be recorded. Clinical interactions are actual appointments during which treatment is planned and/or rendered. Non-clinical interactions include all other activities relevant to your patient (telephone conversations, consultations with faculty, appointment arrangements, cancellations or failed appointments, personal observations, etc.).

Treatment history notes should contain facts and avoid the use of statements that convey judgment of the patient or their behavior. When appropriate you may quote the patient in the progress note to be certain that you have accurately conveyed their sentiment.

A template note is utilized by each student who enters the factors of the treatment delivered for each of the appropriate sections. Any contact with the patient that involves dental care decisions or scheduling appointments must be entered into the record within Contact Notes.

Decisions regarding releases, transfers, referrals, etc. are often based on non-clinical activities such as cancellations, failed appointments, and telephone conversations. The assigned Patient Services Coordinator (PSC) is mostly responsible for these entries into the patient record, but you may be asked to enter any supporting information into the record to assist the PSC in addressing these non-clinical entries into the record. 

Start Check / PTP: This step is critical to the delivery of care for your patient. This acknowledges that you have received authorization to begin treatment on the patient. This authorization is time-coded and must be authorized by the supervising faculty. Any student who begins treatment without this authorization will be subject to a minimum of one-week suspension from the clinic.

       Start: Check Notes/Items:

1. Patient presents for: (planned or proposed treatment)
2. Review of medical status
3. Vitals: current blood pressure, pulse, and respiration reading, temperature, and Covid questions
4. Chief concern
5. Contraindications to treatment
6. Request for permission to proceed (PTP)
7. Additional comments

Treatment Note: Upon completion of treatment, the appropriate template note must be completed.

Treatment Conclusion:  Always escort your patient to meet with the Patient Services Coordinator (PSC). Before checkout, students must have all records completed and authorized by the supervising faculty. The next planned appointment must be in the chart to schedule the patient for the next appointment. If the patient does not have any remaining treatment, then a prophylaxis or maintenance appointment must be planned.

Students are required to enter treatment codes and notes into every patient’s electronic health record after the patient’s appointment has been checked out. The Office of Quality Assurance and Compliance will conduct a daily audit of the previous business day’s charts to identify any missing treatment codes and notes. To guarantee students are correctly reconciling patient charts with missing treatment codes and notes, the following corrective actions will be implemented until rectified:

• Instrument holds – students will be prevented from receiving any instruments from Central Sterilization
• Chart locks – will be applied to any charts on the student’s current schedule to prevent the student from beginning treatment

Missing/Unapproved Treatment Codes

1. An autogenerated amail notification, from axiUm, will be sent to each student provider when a code is missing from a checked-out patient’s chart.
2. If the code is not entered and approved by the faculty for that appointment date, an email from the Office of Quality Assurance and Compliance will be sent to the student provider with a deadline for reconciliation.
3. The student should email the Office of Quality Assurance and Compliance once the codes have been correctly entered and approved by the faculty to prevent the implementation of the corrective actions.
4. Instrument holds and chart locks will be released once the student provider has notified the Office of Quality Assurance and Compliance that the patient’s chart has been correctly reconciled.
5. Student providers must enter missing codes and have faculty approve the codes within one (1) business day. It is the student’s responsibility to contact faculty, either in person (physically locating faculty within the building) or via email and amail to have codes approved.

Missing/Unapproved Notes

1. The Office of Quality Assurance and Compliance will email the student providers directly when any notes are missing from a checked-out patient’s chart.
2. The email will contain instructions for correcting the patient’s chart and a deadline for reconciliation. Missing notes must be entered on the same day as receipt of the email; however, notes are not required to be approved by faculty on the same day.
3. The student provider should email the Office of Quality Assurance and Compliance once the notes have been correctly entered and approved by faculty to prevent the implementation of the corrective actions.
4. Instrument holds and chart locks will be released once the student provider has notified the Office of Quality Assurance and Compliance that the patient’s chart has been correctly reconciled.
5. Student providers must enter missing notes within the same day and faculty must approve the notes within five (5) business days. It is the student’s responsibility to contact faculty, either in person (physically locating faculty within the building) or via email and amail to have notes approved.

Sanctions

Student providers who use another student provider's instruments while theirs are on hold will be subject to:

• First offense- Formal write-up for both students
• Second offense – Formal write-up and possible one-week removal from the clinic for both students
• Third offense - Removal from the clinic for a minimum of two weeks for both students

Instruments must be turned in to Central Sterilization at the end of each clinic day and may not be stored in lockers or clinic bags. Students who use instruments that were not turned in to Central Sterilization because their instruments were on hold will be subject to:

• First offense – Professionalism Concerns Report written and filed in student's record
• Second offense – Professionalism Concerns Report written and two-week removal from the clinic
• Third offense – Recommendation to the Dean and Vice Provost for dismissal from the professional program

An integral part of the student’s education in delivering patient care is learning to document all interactions properly and completely while demonstrating consistent continual dental care for all your assigned patients. Proper record management is important for several reasons. The patient record is a legal document; it affords liability protection to the patient, the student delivering the care, the faculty supervising the care, and the College of Dentistry should any questions arise about the treatment rendered. 

The patient record also contains all pertinent information regarding the patient’s medical, dental, emotional, and behavioral background which may have an impact on the type and extent of treatment provided to the patient. Providing dental care without this essential information increases the likelihood of errors and inefficiency in treatment. The patient record is also the primary source of information for institutional decisions about the patient’s treatment status within the teaching program. Issues regarding the transfer, reassignment, division of care, or referral cannot be defended without proper documentation in the patient record. 

The accuracy and completeness of patient records are also important aspects of the College of Dentistry’s accreditation process through the Commission on Dental Accreditation and the American Dental Association. 

Evaluating the student’s capabilities in these areas is accomplished through participation in an auditing process of their patient records. 

Dental Students: 

Beginning in the fall semester of the junior year, each student will be evaluated during audits of all assigned patient records once each semester. The audit includes a review of all records, an identification of deficiencies as per criteria published in the syllabus, and the assignment of a grade in the fall and spring semesters. 

The Group Practice Director performs the audits on the patient records of their respective DS4 students. The Director of Compliance, Director of Quality Assurance and Patient Relations, Clinical Assistant Professor, and the Assistant Dean of Clinical Affairs perform the audits on the patient records of all DS3 students. 

The Patient Records Audits comprise the basis of Clinical Recordkeeping and Patient Management Courses I-IV, 8105, 8505, 9105, and 9505, respectively. The Director of Compliance is the course director.

Dental Hygiene Students: 

Starting in the spring semester of the first year, each dental hygiene student will be evaluated during an audit of patient records. The student will participate in one audit during the first-year spring semester and two audits per semester during the third and fourth semesters. A grade is awarded in their Clinical Dental Hygiene Course for the accuracy of the records audit.