Information Governance & Standards

Dental Clinical Notes

  • 1.  Dental Clinical Notes

    Posted 08-10-2018 12:42


    My agency is requesting that I provide Approve/Sign Off privileges to our non-clinical staff, such as our front desk staff or non-certified Dental Assistants to enter and sign off "informational" notes that they would enter into the Clinical Notes section in our EDR. I have tried to fight this, but have been overruled. Could anyone provide me with any information to help support my case? Everything that I have read indicates that the Clinical Notes area should only be used by clinical staff to document patient assessments, treatment plans, treatment details, clinical observations, etc. to correlate and support financial processes in the ledger for instance. There are other sections of the system that can be used for information notes, but they want to make this easier for the provider and show all notes in one place. Any guidance would be appreciated.



    Desiree Wesley

  • 2.  RE: Dental Clinical Notes

    Posted 08-11-2018 07:35
    I don't work with dental records.  I hope that others who work with dental records will weigh in on this, but I'll provide my thoughts in case that doesn't happen.  If I were in your shoes, the places I would go to research this include
    • your state's regulations regarding documentation in dental records
    • your EHR system (surely they have something to say about this)
    • your agency's professional liability insurance company to see what they have to say about this
    • American Dental Association resources on dental records and documentation practices

    Judy Bielby
    Clinical Assistant Professor
    University of Kansas Medical Center