The Importance of Written Medical and Dental Records

By: Roger Berger

Have you ever wondered why your dentist checks your blood pressure periodically?  In addition to being a good practice, the Texas Dental Board actually requires dentists to check their patients’ blood pressures and to document that they have done so.  As an attorney who has specialized in defending healthcare liability claims (HCLCs) and Board investigations, good medical/dental records serve multiple purposes. 

First, good records allow health care providers to get a picture of what was going on with patients at specific visits and over time.  More importantly, they help paint a picture of what the treating health care provider was thinking and how that thinking may have changed over time.  This can be especially important for experts who may later be evaluating claims against the health care provider.

Second, the more detailed the health care provider’s records are, the more the defense attorney has to work with.  As anyone who has worked with medical records before knows, no provider can document every aspect of every encounter with every patient – to do so would require that a majority of the health care provider’s time be spent documenting, not evaluating and treating patients.  The key to defending HCLCs and Board investigations is to have references in the contemporaneous charting that the health care provider can look back at and provide details about. 

As an example, an oral surgeon I defended early in my career was sued in part for not obtaining informed consent for extraction of wisdom teeth.  In the lawsuit that followed a jaw fracture during the extraction, there was no written, signed informed consent (nor was one required).  We were able to provide good evidence that informed consent was obtained because the oral surgeon documented in her chart: “DROP-ICO.”  Under cross-examination, the oral surgeon stated that this was an abbreviation that she “Discussed Risks Of Procedure – Informed Consent Obtained.”  She did so credibly and believably because she had the foresight to make a brief notation in the chart on the day of the extraction.

Third, both the Texas Medical Board and the Texas Dental Board have documentation requirements.  Among other things, Title 22 of the Texas Administrative Code, section 165.1(a), requires the following:

1. Documentation for each encounter that includes the reason for the encounter, relevant history, physical examination findings and prior diagnostic test results; an assessment, clinical impression, or diagnosis, and a plan for care;

2. The rationale for and results of diagnostic and other ancillary services;

3. The patient’s progress, including response to treatment, change in diagnosis, and patient’s non-compliance.

4. Relevant risk factors;

5. A written plan for care including treatments and medications (prescriptions and samples), specifying amount, frequency, number of refills, and dosage; referrals and consultations; patient/family education; and specific instructions for follow up.

6. A summary or documentation memorializing communications transmitted or received by the physician about which a medical decision is made regarding the patient.

http://txrules.elaws.us/rule/title22_chapter165_sec.165.1.  The Code does acknowledge that the nature and amount of physician documentation varies by type of services, place of service, and the patient's status; thus, the record-keeping can be modified to account for these variables in providing medical care. (22 Tex. Admin. Code, § 165.1(a)(13)).  There are other Medical Board rules regarding maintenance of medical records, destruction of records, and copies of records.

The Texas Dental Board’s requirements are more thorough and detailed.  Section 108.8(b) states that a dentist’s records must include documentation of the patient’s name; date of visit; reason for visit; and vital signs (including, but not limited to, blood pressure and heart rate).  http://txrules.elaws.us/rule/title22_chapter108_sec.108.8.  Further, section 108.8(c) requires documentation of:

1. Written review of medical history and limited physical evaluation;

2. Documentation of any radiographs taken and findings that were deduced from them as well as the findings of a tactile and visual examination of the soft and hard tissues of the oral cavity;

3. Diagnosis(es);

4. Treatment plan, recommendation, and options;

5. Treatment provided;

6. Medication and dosages given to patient;

7. Complications;

8. Written informed consent;

9. The dispensing, administering, or prescribing of all medications; and

10. Confirmable identification of the dental provider as well as the person making record entries if different from the provider dentist.

http://txrules.elaws.us/rule/title22_chapter108_sec.108.8.

Dental providers also must:

1.   Obtain and review an initial medical history and perform a limited physical evaluation, including allergies to drugs, serious illness, current medications, previous hospitalizations and significant surgery, and a review of the physiologic systems obtained by patient history.  There is a specific rule stating that the limited physical examination shall include, but shall not necessarily be limited to, measurement of blood pressure and pulse/heart rate (which explains why your dentist checks your blood pressure!).

2.   Obtain and review an updated medical history and limited physical evaluation at least annually and when a reasonable and prudent dentist would do so under the same or similar circumstances; and

3.   Obtain a signed, written informed consent for all treatment plans and procedures where a reasonable possibility of complications from the planned treatment or procedure exists, or they involve risks or hazards that could influence a reasonable person in making a decision to give or withhold consent.

http://txrules.elaws.us/rule/title22_chapter108_sec.108.7.

The Dental Board also has additional specific rules for documentation when dentists provide nitrous oxide or sedation.  When nitrous is used, the records must include pre-operative baseline vitals, concentrations of nitrous and oxygen administered, and start and finish times, among others.  http://txrules.elaws.us/rule/title22_chapter110_sec.110.3.

When administering nitrous oxide or sedation, including Halcion, the dentist must create a written or electronic preoperative sedation/anesthesia checklist that includes:

 1.   Medical history, including documentation of the following:

1. review of patient medical history;
2. review of patient allergies;
3. review of patient surgical and/or anesthesia history;
4. review of family surgical and/or anesthesia history; and
5. review of patient medications and any modifications;

2.   Confirmation that written and verbal preoperative and post-operative instructions were delivered to the patient, parent, legal guardian, or care-giver;

3.   Medical consults, as needed;

4.   Physical examination, including documentation of the following:

1. ASA classification;
2. NPO status; and
3. Preoperative vitals, including height, weight, blood pressure, pulse rate, and respiration rate;

5.   Anesthesia-specific physical examination, including documentation of

1. Airway assessment, including Mallampati score and/or Brodsky score as necessary for adequate patient evaluation; and
2. Ventilation and respiratory rate obtained through patient observation, auscultation, or capnography;

6.   Confirmation of pre-procedure equipment readiness check;

7.   Confirmation of pre-procedure treatment review (correct patient and procedure); and

8.   Special preoperative considerations as indicated for sedation/anesthesia administered to pediatric or high risk patients.

http://txrules.elaws.us/rule/title22_chapter110_sec.110.13.

Finally, a dentist administering minimal sedation (a Level 1 permit) must document:

1. The names and dosages of all drugs administered and the names of individuals present during administration of the drugs;

2. A time-oriented sedation record may be considered for documentation of all monitoring parameters; and

3. Pulse oximetry, heart rate, respiratory rate, and blood pressure are the parameters which may be documented at appropriate intervals of no more than 10 minutes.

http://txrules.elaws.us/rule/title22_chapter110_sec.110.4; the above language comes from §110.4(c)(5).  A recent rule change now specifically requires that a dentist who administers Halcion must have a Level 1 Sedation permit and must actually administer (or have the patient take the Halcion) while in the office. http://txrules.elaws.us/rule/title22_chapter108_sec.108.7; subsection 17.

Upon analyzing the rules, the amount of documentation that is required is incredible.  In my experience, very few medical or dental clients maintain that degree of documentation.  Could the Medical Board or Dental Board sanction the average licensee for insufficient records?  Probably.  Would they?  In my experience, the Boards are less likely to sanction a licensee for record-keeping violations as long as the care rendered was reasonable and, most importantly, if the contemporaneous records contain sufficient information for the licensee to expand on what was documented in a narrative or rebuttal.  The same applies to a health care liability claim.