As a dentist you are responsible for sensitive patient information. Be sure you know the facts about storing dental records. Learn about it here!
There are 200,000 dentists in the United States and storing patient dental records of the millions of patients they see is important. Not only do you need to keep them confidential, but you need to ensure that they are destroyed on time depending on the situation.
Depending on what country you live in, keeping dental records confidential can be a matter of legality. And while there are legal issues to consider, your staff should also be able to sort through the records without too much headache.
In this article, we’ll discuss some of the best practices for storing dental records to ensure ease of use and patients’ privacy.
Why Are Dental Records Important?
Dental records refer to patients’ charts. They contain all the information about treatment and their current and past health. They are important in a variety of ways, which is why your staff needs to know how to readily access them.
Firstly, the dental record helps the dentist treating them understand the patient’s history. It is also helpful when referring the patient to another dentist or specialist, as it gives them an idea of their past history.
Dental records are also extremely important if someone goes missing. Forensic scientists can use dental records if they suspect a body found is someone from your practice. They can use the records to identify the remains.
What Do Dental Records Include?
A dental record will include information about the patient such as their date of birth and other health issues they may face. This is important as some diseases may cause damage to the teeth. Typically, the name of the patient will only appear on the front cover of the file to keep anonymity.
Most often, the name is written in the following order: surname, first name, middle name and then any titles like IV. You should also include the patient’s account number and any color-coded information that your office uses to keep track of patients.
Inside the file, the dental records will include things like X-rays, past treatments, antibiotics prescribed and files from other dentists they may have seen. This is especially true if your office referred the patient to a specialist at some point.
A dental record should not include insurance or financial information. This is kept separately from the patient’s health file.
The American Dental Association states that opinions and criticisms about the patient should not be included in the patient’s file. Instead, the file is strictly clinical in nature, discussing recommendations, past treatments and anything else the treatment provider believes is relevant.
Who Should Have Access to the Records?
Only authorized individuals should have access to patient records. This should only include the dentist and any dental nurses or assistants who may treat the patient. In many smaller offices, all of the information is stored on a computer with only certain staff members having access to the files.
If stored physically, the records should be in a room with a staff member at all times. This is to comply with HIPAA and their privacy act, which states that legally only certain people are allowed to see the confidential patient information.
If not in the United States, like TL Dental, there will be different guidelines for patient confidentiality. However, it is good practice to ensure that patient files are not open to the public or unauthorized individuals.
How Are Records Stored?
Today, many records are stored on computers in digital databases. However, most offices still keep a file system. This allows them to see hard copies of things like X-rays and prescriptions without having to log onto the computer.
In most cases, each patient record is placed in a folder. The staff organizes the records by surname. They may use color coding to find files more easily and prevent digging around in the drawer keeping a patient or dentist waiting.
The files are typically placed in a file drawer. Staff should monitor the drawer at all times to ensure that no unauthorized individuals look at staff information.
Inactive Versus Active Patients
Your practice should regularly switch patients from active to inactive. This is to ensure that you keep your records up-to-date. Inactive patients are those who have not visited your practice in a certain amount of time.
Typically, patients are put into three categories. The first category is for patients who have visited the office in the past 12 months. The second category is for patients who have visited in the past 24 months but not 12 months. The third is the inactive patient category, of those who have not visited in 24 months or longer.
When to Destroy Records
Your office and state (or country) will have a policy on how to destroy dental records. Although you should retain most of your records, there does come a time when records do need destruction. This can be after the death of a patient, when the minor patient becomes an adult, the incompetence of the patient and whether the patient was on Medicare or Medicaid.
Most often, you will need to have a witness to the destruction and files will need to be destroyed by incineration or shredding. You need to delete electronic files completely. This means not just hitting “delete,” but ensuring that the file no longer exists in its raw form on your computer.
Your office will create a records retention policy that will include how to destroy records and the protocol to follow.
The Best Practice with Dental Records
When storing dental records, the best practice is to be prudent and cautious. Never let anyone see information that they do not need to see, as this can land your practice in serious trouble. Instead, ensure that files are either physically in a place where authorized staff sits at all time, or locked up safely behind a passcode on the computer.
For more information on small businesses and small business practice, visit our website.