Patient Records

Most likely if you practice long enough you will be sued. Your progress notes are your best defense. The reason you can't white out or completely cross out your records is because you are not allowed to alter this legal document for any purpose. Write your records with a lawsuit in mind.

When I was in practice, if I asked a patient to go to a periodontist and they gave me a reason why they couldn't, I wrote it down. "My daughter is getting married...We just bought a new car." I would also try to note where the daughter was getting married and the kind of car they bought.

If you give local anesthesia without epinephrine...write it down. If you don't give anesthesia for a procedure that you might normally give anesthesia then write down "no anesthesia."

After you take the blood pressure, write down the numbers.(What do you do if it's 200/100 or 160/90?). In one of these cases you should let the patient sit in the waiting area. You don't treat if the top number (systolic) is over 180 and if the bottom number (diastolic) is over 100.

When you do an adjustment, write down exactly where, e.g. the buccal border opposite tooth #2. In practice you will be doing a few dentures at the same time and will not remember where you did the adjustment. The patient will feel better when they come back and you ask them "How does it feel on the upper right side?" Don't just write "second adjustment, or adjustments made with pressure indicating paste" because it is meaningless.

If the patient says something nice write it down. "I had no pain at all." "I could eat peanuts with these dentures."

You want to show that you are following accepted methods of treatment.

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©1999 by Julius Rosen, D.D.S.