Why Good Dental Records are Essential and How to Audit Them


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Nov 07 2017 40 mins  

On this episode of Talking with the Tooth Cop, I explain seven of the most important things to look for in your dental records. I also describe different types of audits that can be used to ensure efficient and effective record-keeping practices as well as explain why all of these processes are critical in your dental practice. Keeping proper records goes beyond preventing lawsuits and insurance headaches. It enters into the realm of ensuring adequate patient care and doing your best to operate the best practice for your patients and staff alike. Be sure to catch the full episode for all the details!

Why you need to ensure exceptional dental records via auditing

In my experience, I have learned that unfortunately, most schools do not teach the critical skill of writing good records. In a constantly changing regulatory environment, stellar recordkeeping provides an invaluable layer of security to your practice. Even though it’s easy to become complacent in mundane office-keeping tasks, proper records are essential. They provide an ongoing, chronological record of what you did, why you did it, when it happened, and how you performed the procedure. Essentially, they enhance patient care. Don’t forget to listen to the full audio to discover all seven items to look for in your records!

Types of audits used in dental practices

On this episode, I explain a variety of different types of audits that can be used in your practice. Prospective/pre-bill audits occur on a daily basis and essentially check for missing line items in billing. It’s always easier to take the time upfront to check for accuracy, and I guarantee it’ll save your billing staff incredible amounts of time in the future. Issues with under and over-payments to insurance companies take away from the time you could be spending working directly with patients and building up your staff. Daily auditing is one thing you can do that can impact your bottom line. For more information on retrospective audits, comprehensive audits, and focused retrospective audits don’t miss this informative episode!

Comparing clinical notes with your dental records - a crucial step

Every dental practitioner and his/her staff should constantly ask themselves, “Do the clinical notes describe every aspect of the billing records?” The balance between clinical notes and billing is immensely valuable when taking preventive action against unnecessary paperwork and insurance issues. It’s important to carefully examine the claims you submit to insurance providers and look for red flags that would point towards gaps in information. This episode is full of helpful information that will make your practice and your office run much smoother - you don’t want to miss it.

Dental records as justification for patient treatment

For cases of restorative and needed treatment, dental records serve as a backup layer of information in the event of an audit. They describe why a particular diagnosis was given, why a procedure was recommended, and the follow-up care that was prescribed. When dentists are audited, the first layer is typically not done by a fellow dental professional. Having accurate records laid out in layman’s terms can exponentially speed up the audit process. It’s important to always be examining ways in which record-keeping habits can be tweaked and improved upon. You don’t want to miss the rest of this insightful episode of Talking with the Tooth Cop.

Outline of This Episode

  • [0:25] Introduction of this episode’s topic - 7 Things to look for in your dental records
  • [10:45] Types of audits - prospective/pre-bill audit
  • [13:38] Types of audits - qualitative retrospective audit
  • [14:27] Types of audits - comprehensive audit
  • [15:28] Types of audits - focused retrospective audit
  • [16:40] Dental records complying with regulatory requirements
  • [19:38] Examining records for clinical notes
  • [22:32] Overview for the top 7 things to look for in dental records
  • [26:20] Double-checking clinical notes and dental records
  • [30:24] Records as justification for patient treatment
  • [35:11] Timeline for record retention

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