1 Clinical Records That Prevent Criminal Records: AKA: Do Dentistry, Not Time Email: roy_shelburne@hotmail.com September 4, 2016
Disclaimer: 2 I am not an attorney The comments and observations made in this presentation are not to be taken as legal advice The material shared is based on my understanding of best practices The information I share is my opinion and is based on my experience and subsequent research I cannot promise that implementing the systems I recommend will ultimately prevent legal action
3 Most of the time, the hard part is not making a decision, it is living with it.
Today's Legal Environment 4 Malpractice Claims Extractions: Infections involving hospitalization Fractured Mandible Sinus Perforation Extraction of wrong tooth TMJ Injury Lingual nerve injury Endo Infections involving hospitalization Broken instruments Nerve Damage Perforations
5 Implants Unrestorable Implants Implants placed in nerves Implant loss Substandard Crown and Bridge procedures Periodontal disease, failure to diagnosis and/or treat Ortho Root resorption
6 General anesthesia complications Handling of dental infections Dental injections Parasthesia Adverse Drug Reactions TMJ and Orthognathic Treatment/Surger Oral Cancer Failure to Diagnose
Today s Legal Environment 7 Board of Dentistry Actions Reimbursement Concerns
8 Things I know now that I wish I had known then! It is a wise man who learns from his mistakes. A wiser man still learns from the mistakes of others.
Where does the buck stop? 9 With the Doctor! Everything that is in (or not in) the record Everything that is coded, correctly or incorrectly Everything that is billed to the patient and/or any third party Everything that is received into the office
And with the Staff 10 The last indictments have included staff members
The necessity of intent. 11 The law states: No specific intent to defraud is required. The legal definition of knowing : knowing (is) to include not only knowledge but also instances which the person acted in deliberate ignorance or reckless disregard of the truth or falsity of the information As a dentist, we should know, or reasonably should know what we and our staff are doing.
12 Pain is inevitable Suffering is optional
Do Dentists Always Agree? 13 Five different dentists examine the same patient how many different treatment plans would be produced? Who is right and who is wrong? Among dentists, that s a difference of opinion and/or practice philosophy Among government regulators, insurance auditors, and regulatory boards, It may be a criminal act!
14
What I learned during the trial 15 About record-keeping - be defensive. If it is not in the patient record 1. It was not seen 2. It was not said 3. It was not heard 4. It didn t need to be done 5. It wasn t done 6. It doesn t exist from the legal perspective
What? 16 The record must establish: Who: Why: Medical/Dental necessity Diagnosis What: Service performed When What specifically was done and used How the procedure was perfumed
17
Who Dictates What Is In The Record? 18 State and federal laws or regulations determine how it is handled, how long it is kept and who may have access to the information. (See you state s Dental Practice Act)
Why spend so much time and effort? 19 What are the arguments? It takes too much time I m a dentist, you can trust me What difference does it make, anyway? Are the arguments valid? Can the objections be overcome?
20
21 Who does the charting?
Use of Abbreviations and Acronyms 22 WNL? Have a universal key readily available providing definitions for all abbreviations and acronyms.
Record Audits: 23 Today s self audit begins Remember: nobody is perfect! The longest journey begins with the first step Be honest with yourself
24 1) Comprehensive Medical and Dental History Patients forget Patients don t think it s important Patients are ashamed Patients lie
25 Have You Had One of These?
26 Or Something Like This?
2) the Histories must be reviewed and 27 documented Review the history thoroughly at the first visit Review histories before each visit thereafter Even if seen 2 times on the same day
What s the Big Deal? 28 The average number of prescriptions per elderly person (over 60) grew from 19.6 in 1992 to 28.5 in 2000, an increase of 45 percent. By 2010, the average number of prescriptions per elderly person is projected to grow to 38.5, an increase of 10 prescriptions, or 35 percent, per senior since 2000. From 1992 to 2010, the average number of prescriptions per senior will grow by 96 percent. The overall total number of prescriptions for seniors grew from 648 million in 1992 to over 1 billion in the year 2000 and is projected to grow to almost 1.6 billion in 2010. http://www.familiesusa.org/site/docserver/drugod.pdf?docid=726
29 3) Documented Detailed Clinical Examination/Evaluation Hard and soft tissue exam The #1 deficiency in the clinical record Soft tissues: lips, gingiva, buccal mucosa, tongue palate: Periodontal evaluation/charting for every patient Hard tissues: Bone and teeth: Radiographs/Photograph (Include reasons for x-rays)
30 Caries Risk Assessments
31 4) Record Normal Findings and Abnormal findings Head and neck Soft tissues/photos Hard tissues/radiographs/photos TMJ evaluation
5) Chief Complaint 32 Why is the patient in your office? If no problem is stated, record the reason for the visit. I need a checkup. Be aware that the chief complaint may change
33
6) Make your notations at the time of 34 the visit Your memory is best just after the examination/treatment Others can write the note (unless prohibited by statute), but Dr. should review and sign. Anyone who makes an entry in the record should sign it and the Doctor review and sign The end of the day is too late A day or 2 later is completely unacceptable
7) List a definitive diagnosis 35 At the end of the examination appointment there should be a definitive diagnosis for all abnormalities noted and all subsequent visits should address that condition. If a definitive diagnosis is not possible without further information or consultation, the plan for determining the diagnosis should be addressed.
36 8) Treatment Plans should address all abnormalities If there is an abnormality, the treatment or referral for that condition should be listed It s OK to determine not to treat Note: reason for treatment, to delay treatment, or not to treat It s OK not to know, but make arrangements to find out (have and outline the plan)
9) Informed consent 37 Consult with you malpractice carrier Implement their protocols Maintain the systems
Informed Refusal 38 The dentist must inform the patient about the consequences of not accepting the treatment and obtain a signed informed refusal. Obtaining an informed refusal does not release the dentist from the responsibility of providing a standard of care If the patient refuses to have radiographs taken, the dentist should refer the patient to another dentist when the original dentist believes that radiographs are a necessary prerequisite to proper care in that case.
39 10) Establish the expectations from the patient Inform the patient of their partnership in treatment Who owns the treatment provided
11) Treatment Rendered 40 Anesthesia: amounts, types, and locations Numbness Procedure Materials uses Any negative outcomes Does stuff happen? Inform Deal with additional treatment/referrals Refusal of recommended treatment
12) Reason for next appointment 41 Treatment should be sequenced to address the condition of greatest concern Address the chief complaint Address the reason for the sequence Get agreement from the patient for the next appointment
13) Note any referrals 42 Where was the patient referred? Reason for the referral Lack of compliance
14) Cancelled/Missed Appointments 43 Compliance can be very important to outcomes
15) All Prescriptions written 44 List prescriptions separately and include number and strengths Indicate what the prescription is to treat Inform the patient of any possible side effects What to do if they experience any untoward effects from the medications
45 Including Lab Prescriptions
16) Do not modify entries 46 Use ink If corrections are needed: Mark through the faulty entry with a single line so the entry is still legible Date the correction Identify the reason for correction No white out or sharpie black out areas
17) All phone conversations 47 Conversations with business staff Conversations with clinical staff Conversation with the Doctor Conversation with the referring Doctor
Patient Compliance: 48 Cancelled and missed appointments Attempts to contact the patient
What About Templates? 49 What does using large bulks of information about the patient using templates indicate? Are all your patients exactly the same? If templates are used (and I m an advocate of using helps to make a complete concise entry) what should these templates look like?
50 Things that do not belong in the treatment record! Only the truth, the whole truth, and nothing but the truth belong there! Not everything that is true about the patient belongs in the treatment record.
2) Do not include financial information 51 Business is separate from treatment Perceptions are very important!
Intent To Do It Correctly Components of an Effective Compliance Program 52 Conducting internal monitoring and auditing: Implementing compliance and practice standards Designating a Compliance officer or contact Conduction appropriate training and education Responding appropriately to detecting offenses and developing corrective action Developing open lines of communication Enforcing disciplinary standards through wellpublicized guidelines
53
54 Once a decision is made to make a positive change, don t look back unless you ve decided to go in that direction!
Never take for granted what you have been granted!
Questions?
Thank you! www.royshelburne.com 423-552-6111 email: roy_shelburne@hotmail.com