“We always take our patients' blood pressure.” That's good. But from a dental record-keeping standpoint, there is another question: Is the blood pressure actually documented in the patient's record? Texas Dental Board rules address the patient's medical history and limited physical evaluation, which includes blood pressure and pulse or heart rate. If the blood pressure was taken but the reading was never entered into the record, someone reviewing that record months—or years—later may have no...

A treatment plan may clearly show what treatment the patient ultimately selected. But does the dental record also show the recommendations and alternatives that were presented along the way? That distinction can become important when the record is reviewed months—or years—later. The final treatment plan may establish the decision. But the rest of the dental record should help establish how the dentist and patient got there. Does your treatment plan document enough? In my latest short video,...

Who Provided the Treatment? Who Made the Record Entry? Everyone in the dental office may know who treated the patient. They may also know who entered the information into the dental record. But will someone reviewing that record two or three years later be able to determine the same thing? The dental record should clearly identify both the individual who provided the treatment and the individual who made the record entry. That distinction can become particularly important when a record is...