Dental Record Protocol

Record Policies and Procedures

1. With the exception of orthodontics, and oral surgery private practice, all patient records are kept in the files of the record room of the Clinic Financial Office located on the fourth floor in room 401. Every patient seen in the school is assigned a record number. This number is used to identify the record folder of each patient. All diagnostic materials including radiographs must remain in the patient's record. Patient records are vital in monitoring patient care and are used for legal purposes and may be read verbatim in court.
2. In the interest of professional dignity and good taste, patient records should be free of facetious remarks and uncomplimentary comments.
3. Progress notes must be entered regularly, particularly where there is a change in clinic course of therapy. It is important that these notes reflect the current condition of the patient and the proposed treatment plan as it changes. All progress notes must be written in ink and legibly signed by the student and faculty member with degree noted.
4. Under no circumstances should any portion of the record be removed. The removal of portions of the record for any reason is a very serious issue. The loss of any portion of a record, particularly radiographs, may imply that they were removed deliberately in order to suppress evidence of patient care. In the event that legal action were brought by a party against the school, this could have serious consequences.
5. Records are the property of the School of Dental Medicine. All patient records must remain on the school premises. Removal of a patient record, or any part of it, from the school is a major offense and may result in disciplinary action.
6. The person who signs out the record is responsible for returning it. No record is to be given to another student/resident or department. If a student signs out the chart for another and it is not returned, he/she will be suspended from further access to records.
7. All records signed out by students must be returned to the reception desk or the record room at the end of each day
8. Mentors perform record reviews according schedule.

Failure to comply with the dental record policy will result in the following sanctions:

1. After the first failure to return a record the student must, upon notification, immediately return it to the Record Room. This applies even if the student is treating a patient.
2. After the second failure the student may be suspended from class and clinic activity for one week.
3. After the third failure the student may be suspended from class and clinic activity for six months.
4. A fourth failure may result in dismissal from the school.
   

Guidelines for Adherence to Dental Record Policy

The following record access policy is in effect and must be strictly adhered to:

• All properly appointed patient records will be available at the second, fifth and seventh floor desks on the morning of the appointment. The records are requested according to the schedule, by clinic coordinators. Records that have outstanding balances due are not released from the record room until payment has been made.
• On the occasions that you would like to see a patient's record when there is no scheduled appointment you may fill out a request sheet before 11A.M. at the appropriate reception desk. These records will also be available at the desk on the requested day.
• You, the patient, and the Clinic Financial Office will benefit from this procedure. All records must be returned after each treatment visit. This return must be complied with as another student may need the record the next day or in the event that the patient presents for emergency service their record must be available. FAILURE TO RETURN A RECORD WILL SUSPEND YOUR RIGHT TO REQUEST ADDITIONAL RECORDS.
• With reference to record access for emergency treatment, those records will be available at the Record Room upon request. It is also understood that there will be cancellations. Last minute appointments made to fill cancellations will be handled expeditiously as exceptions to the above policy.
• Record entries must be legible and precise. Details of every procedure completed, materials used, patient comments and so forth are absolutely essential components of a patient record. The following section on record entries covers this in greater detail.
• Original radiographs or other portions of the record are not to be given to the patient. If a patient wishes his/her radiographs or other portions of the record, the patient must request this in writing from the Clinic Financial Office. Copies of the records will be released in accordance with the laws of the Commonwealth of Massachusetts for a nominal fee.
  

Recordkeeping Procedures

Making accurate and complete record entries is a crucial area of professional responsibility in which students entering the clinical phase of their training must rapidly discipline themselves. A record entry must be made for every patient interaction that occurs, from a missed appointment to a final cementation and including all relevant opinions or comments expressed by the patient regarding his/her treatment.

The importance of accurate record keeping is threefold. First of all, as the Dental Record Policy emphasizes, the dental record is a legal document and is primary evidence if legal action is taken against an institution or private practitioner. It therefore should document sound clinical judgment on the part of BUSDM students and faculty and demonstrate that measures were taken to ensure patient comfort and the safety and success of all treatment rendered.

Second, the patient record is the mechanism by which insurance claims are filled out, itemized statements prepared, and charges are reviewed for accuracy. In order to determine charges accurately, the details of each procedure must be enumerated, e.g., number of surfaces, tooth number, types of restorative materials, types of cement and so forth.

Third, in the School of Dental Medicine a patient may be treated in several different clinics both by predoctoral and postdoctoral students. To insure the smooth transition of a patient from clinic to clinic, information must be easily transmitted as well. The patient record is often the sole source of vital facts concerning patient treatment status. Respect for the efficient use of the time of all involved--patients, fellow students, faculty and staff--is the final reason for making complete and legible record entries.

ALWAYS include the following information (when relevant) in record entries in ink:

1. Be sure to legibly record the date of treatment and treatment rendered in the record. Note every date of patient visit, missed appointment, etc.
2. Make a note of the type and amount of all drugs (anesthesia) administered and/or prescribed.
3. Describe the procedure in detail. Include such information as tooth number and surfaces, type (brand name) and amount of materials used, precise location, etc.
4. Make a note of complications, if any. Indicate awareness of medical complications if warranted.
5. Detail any instructions to a patient.
6. Make note of all patient comments, positive or negative. Any substantive communication between patient and student or staff should be indicated.
7. Make a note of all consultations held with faculty members.
8. Signature of student in ink.
9. Signature of faculty members with their degree in ink.

If there is any doubt as to how to describe or write up a patient encounter, request assistance from a faculty member.

Obtaining and Returning Records

Records for patients with appointments will be available at the reception desk. They will be filed by patient record number. Students may ask any Coordinator for their patient’s record BY RECORD NUMBER. STUDENTS WILL NOT BE PERMITTED BEHIND THE RECEPTION DESK TO RETRIEVE RECORDS.

No patient may be seen unless the patient’s record is present in the operatory. The completed record and signed tx plan are to be brought together with the patient to the reception desk at the conclusion of the visit. At that time the patient pays for their appointment and an appointment is made for the next appointment.

If you are seeing the patient the next day, ask a coordinator to hold the record for you. Otherwise, the record will be returned to the record room.

To Obtain a Record on the Day of the Appointment

Present at the reception desk with the patient’s record number. The chart will be requested The record is to be returned to the reception desk following the appointment.

For Record Reviews with Mentors

Request a computer printout for final record reviews or if requested by the educational support staff at the Reception Desk.

Request records from the Record Room three days in advance of meeting.

To Obtain a Single Records for Review or Faculty Signature (Nontreatment)

To request a single record or records (up to three at a time) for non-treatment at the reception desk, put your name, the chart number and date on the request clipboard before 11AM. Your record(s) will be available at the desk after 1PM. Records cannot be taken out of the school. The fifth/sixth floor has a one day hold bin which can be used if necessary. Any records in that bin for more than one day will be returned to the record room.

Introduction to the Record System

NOTE: ALL RECORD INSERTS REFERRED TO IN THIS CHAPTER ARE AT THE END OF THIS SECTION.

This manual includes a sample record with all appropriate forms The record system is color coded, tabbed, and individual pages are to be attached into the record folder in the order listed below.

We will follow a patient model (John Doe), through the dental school to illustrate the new record system.

Mr. Doe is directed to the first floor desk where he registers and obtains a record folder The record folder includes:

• Front cover
• Back cover: "Informed Consent"
• Patient information

Mr. Doe is then directed to oral diagnosis where he obtains the following forms for the record:

• Sequenced Comprehensive Treatment Plan
• Chronologic Record of all Treatments/Visits
• Medical History
• Dental History
• Radiology Permission
• Clinical Exam and Screening

Mr. Doe is instructed to complete the medical and dental history, patient information, and patient application for treatment. Mr. Doe enters the Division of Oral Diagnosis for a preliminary diagnosis; assigned student(s) will review the medical and dental histories with the patient; record blood pressure, perform an intraoral and extraoral exam and place this information where indicated on the Clinical Exam and Screening Form and sign and complete these indicated forms with the patient's name, record number and date. After this has been completed, the patient is brought to Radiology. Before any radiographs are made, the Radiographic Permission form must be completed for all present (and future) radiographs.

As every treatment or visit is accomplished, it is recorded on the Chronologic Record of all Treatments/Visits and the name of the patient, record number, dates, his/her signature and faculty signatures are absolutely required.

The patient is assigned to student(s) for dental treatment. In this example, the primary care dentist would be the pre-doctoral student, who would coordinate Mr. Doe's treatment .The names of these assigned students are placed (by the individuals assigning these patients) on the bottom left hand corner of the patient information page of the record folder. In this case, the pre-doctoral student obtains the necessary departmental consultations, and specialist information, and incorporates them into a Sequenced Comprehensive Treatment Plan. The student also discusses the specific fees for prescribed treatment.

Diagnosis and Consultation Form

The student completes all sections: Intraoral Examination, Gingival Soft Tissue Findings, Oral Hygiene, Occlusal Screening Evaluation, Periodontal Findings, Tooth Charting for pocket depths, mobilities, etc., Radiographic Findings and Treatment Plan.

The charting of missing teeth and existing restorations is completed according to Specific Charting Guidelines. The student constructs a diagnosis, treatment, and sequence for each tooth requiring therapy. Restorations and treatments are charted as completed, only in black .

Chart proposed restorations according to specific Charting Guidelines. The student will develop a diagnosis and treatment and record the information where indicated on form.

For any patient that requires a partial denture, the student must complete the framework design to the satisfaction of the removable faculty. This must be accomplished before a complete treatment plan is approved .

Occlusal Examination

Information to complete this form will be provided in occlusion lectures.

Endodontics

Endo consults are obtained from the endodontic resident on emergency.

STUDENTS MUST BE PREPARED TO DISCUSS ALL OF ABOVE.

Clinic Payment Policy and Contracting Procedures

One important factor in patient treatment and management is how well-informed and systematic the student is in handling patient's financial arrangements. If the student is aware of proper financial procedures, and assumes the responsibility for educating and preparing the patient for each step of treatment and payment, valuable time can be saved and patient confidence and satisfaction can increase.

Students are expected to observe the following procedures as established by School of Dental Medicine payment policy:

1. Patients are seen in oral diagnosis where they pay initial fees for registration, radiographs, and consultations. They will receive an estimate of treatment cost, which must be identified as only an approximation. This cost quotation should be conservative enough to allow for unforeseen complications or changes in treatment.
2. The dental clinic billing procedure is on a current basis and previous balances cannot be carried. All outstanding balances must be paid for in full before any new treatment can be done. In addition, new treatment must be paid for in full on the day of the patient's treatment. The only exception to this policy is for those patients who are covered by a payment contract.
3. In predoc, all cast gold procedures must be contracted.
4. In postdoc restorative, all restorative procedures are contracted.
5. All orthodontic treatment is contracted.
6. All endodontic treatment is contracted.
7. Removable prosthetic treatment must be contracted. The patient must sign the contract and pay one-half of the amounts contracted before work begins and pay the final half before the final cast is sent to the laboratory.
8. In predoc, all fixed prosthetic treatment must be contracted and the first half of the amount contracted must be paid before any stage of treatment is initiated. The second half must be paid before the case is sent to the laboratory or before metal is issued. Only metal for post and cores may be issued upon 50% payment. Contracts for single units are payable in full when signed.
9. In postdoc restorative, all treatment is contracted with payments in 1/3 increments.

When a treatment plan involves an area of dental treatment handled under contract, the student must draw up a contract for fixed and/or removable treatment. The patient must be available to sign the contract and make the initial payment at this time. If there are any changes in the course of therapy or if a patient does not proceed with the treatment he/she has contracted for, the student dentist must immediately notify the Clinic Financial Office of this situation.

Students are advised to inform the patient under contract as to what stage of treatment they are undergoing and what the expected timetable for payment will be. Avoiding communication on financial matters is not only impractical, it is disturbing and misleading to the patient who is relying on the student to be candid and considerate of their relationship.

Patients who express dissatisfaction should be listened to with an open mind (and have all their comments duly noted in their record). Students must never assume the responsibility for making financial adjustments, and must in no way imply that this is possible. Adjustments will be handled only by department chairpersons or the Directors’ of the Predoc and Postdoc clinics.

Restorative/Periodontic Procedures

Operative contracts are available at the reception. You must have the signed treatment plan each time you see the patient to continue the contracted treatment. Check the “continuing treatment” procedure and enter the contract number if available. If more than one procedure is being performed, check the “other” and enter code, procedure, tooth number, and surface code.

Periodontal Procedures

A treatment plan must be presented for each appointment. If a prophylaxis/scaling will take more than one visit, the patient is to be charged and expected to pay on the initial visit. The second visit will be entered as continuing treatment. Periodontal surgery performed in the predoctoral treatment center is to be charged and paid for at the reception desk. Surgery performed on the second floor is to be charged and paid for on the second floor. Prior approval must be obtained before performing surgery for patients covered under MassHealth. Faculty must sign the treatment plan to indicate daily treatment and charge status for each patient.

Fixed/Removable Prosthetic Procedures

Fixed/removable contracts are prepared at the reception desks. No contractual treatment is to begin until a contract is signed and paid for. A treatment plan is to be presented completed for each continuing appointment t. Prior approval must be obtained before starting treatment for patients covered under MassHealth. Faculty must sign the the treatment plan where indicated.

Endodontic Procedures

Endodontic contracts are prepared on the first and second floor endo offices, behind the reception desk. No endodontic treatment is to be started until a contract is signed and paid for. A treatment plan is to be presented for each continuing appointment. Prior approval must be obtained before starting treatment for patients covered under MassHealth. Faculty must sign the treatment plan where indicated.

Insured Patients

Boston University School of Dental Medicine at 100 East Newton Street does not accept direct insurance payments for services. Students whose patients are expecting their insurance to cover the cost of dental care must alert their patients to this fact. The Clinic Financial Office will fill out insurance claim forms so the patient may be reimbursed only after all work is completed and paid for in full.

All claim forms must be brought to the Clinic Financial Office (room 402) with the patient's chart. At times, a patient will request a pre-treatment estimate to be sent to their insurance company to determine in advance how much of their work will be covered. In these cases, the record and the insurance forms must be submitted before treatment begins. It is recommended that a pre-treatment estimate be sent for all cases requiring a large amount of work (in excess of $400). Some insurance companies require the pre-treatment estimate. It is good practice to request insurance forms from the patient and review the required procedures. Statements of diagnosis and treatment plans must be explicit, clearly rationalized, and legible, containing all the required signatures to allow for swift and reasonable review by the insurance company.

Note: Boston University offers a dental insurance plan to all eligible employees and their dependents. Participants in this insurance plan are covered only for services rendered by a graduate resident or faculty member at the Dental Health Center on the seventh floor of BUSDM at 100 East Newton Street or the Dental Health Center located at 930 Commonwealth Avenue.

MassHealth Patients

All MassHealth patient records are identified by a green label on the front cover and have a copy of the patient's eligibility card stapled inside. Eligibility cards are issued by the Department of Public Welfare. No chart will be released unless a current eligibility card is available. Copies of the cards can be made at the fourth floor desk. It is your responsibility to inform your patients of the necessity of bringing their current card. No treatment can be rendered without a valid card.

In general, limitations are placed on the nature and extent of dental services, which can be provided without prior approval. They are as follows for patients under the age of 21:

1. Simple extractions
2. Emergency services, with a copy of the operative report.

Prior approval must be sought for all periodontal therapy; endodontics; prosthetics (crowns, cast cores, dentures); pedodontics; other than routine restorations; orthodontics and oral surgery other than simple extractions. No Mass Health patient can be asked to pay for any procedures requiring a prior approval until the prior approval application has been denied or asked to pay for any procedure that Mass Health will reimburse payment for. Patients who become ineligible for benefits before completion of treatment are responsible for payment in full. Prior approvals are not valid if a patient has been discontinued by MassHealth.

In order to secure approvals promptly, the following information must be presented to the Mass Health coordinator in the Business Office.

1) Periodontics

• a brief outline of the planned surgical procedures
• pocket depth charting form
• full mouth radiographs or panorex
• patient record

2) Endodontics

• a statement of the need for treatment
• full mouth radiographs or panorex
• patient record
• NO treatment other than emergency, may be rendered until approval is obtained

3) Prosthetics

• signed treatment plan
• if dentures are replacement dentures, a statement of the need for new dentures must be provided
• if a partial denture is needed, a partial design, signed by the removable faculty is required
• patient record
• NO treatment, other than emergency, may be rendered until approval is obtained

4) Oral Surgery

• full mouth radiographs or panorex of teeth to be extracted or area requiring surgery documentation of diagnosis and treatment plan signed by faculty
• NO treatment, other than emergency, may be rendered until approval is obtained

5) Orthodontics. See clinic coordinator

6) Pediatric Dentistry

• a statement of the need for treatment
• full mouth radiographs or panorex or slides
• patient record
• NO treatment, other than emergency, may be rendered until approval is obtained

Official Dental School Discount Policy

BUSDM student

Must be a full-time registered student with the BUSDM registrar responsible for certification of eligibility if need arises. Student discount is 100% and work must be performed by a graduate or undergraduate student. Anesthesia for oral surgery is not covered by this discount. Eligible student must pay all inside or outside lab charges plus gold. All work normally requiring a contract must be contracted. All current clinic manual policies must be followed for all discounted students. Discount eligibility ends at graduation, withdrawal, or leave of absence, whichever occurs first. Following the aforementioned action, prevailing school rates and payment policies will be in effect for new or unfinished treatment.

Student Family Discount Policy

To lessen the financial burden of caring for dependents, students and residents are granted the privilege of treating their own immediate family at no cost other than applicable laboratory fees. The immediate family of students and residents may also be treated by other approved members of the dental school community at a discount of 50% from regular fees or 50% from the remainder of regular fees after all laboratory expense have been paid. "Immediate family," for purposes of this discount, will be defined as a current spouse and /or dependent children. All other family members will be required to pay our regular fees, which are significantly below those in outside private practice.

Students and residents applying for the discount will be asked to sign a statement affirming that the patient is, in fact, their current spouse or dependent child. A misrepresentation on this point will be considered a serious offense and appropriate and severe sanctions will follow.

The administration is confident that these changes in the "Family Discount Policy" will enable the school to continue to offer a well-deserved courtesy to the tuition paying members of our school--those who need it most.

Application forms for this discount selection are available in Room 529 located of the fifth floor of BUSDM
.
Note: The Oral Surgery Group Practice and any other group (faculty) practices are not covered by this discount policy. Also, implant procedures in periodontics and prosthetics are not covered by this discount policy.

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