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...

Does your dental record include your radiographic findings? Taking a dental radiograph and documenting what you found on it are two different things. A progress note may clearly establish that bitewings, a periapical radiograph, or other diagnostic images were obtained. But does the record also document the findings you observed on those radiographs? That distinction can become important if the dental record is reviewed months—or years—later. Texas Dental Board record-keeping requirements...

Three pieces of information in a dental record seem almost too basic to discuss: The patient's name. The date of the visit. And the reason for the visit. Yet basic information can become surprisingly important when a dental record is reviewed months—or years—after the treatment occurred. The people reviewing that record later weren't necessarily in your office. They may be another dentist, an insurance carrier, an attorney, an expert—or the Texas Dental Board. And they shouldn't have to make...