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.
