What are the required documents in your patient files?
CONFESSIONS, INSIGHTS, and ADVICE
From a Dental Board Investigator
What are the required documents in your patient files?
As Deputy Chief Investigator for the Arizona Board of Dental Examiners, I reviewed nearly 1,000 dental complaint files and worked with dentists, patients, attorneys, and the Board. My experience as a dental expert witness in lawsuits, depositions, professional opinions, and trials for both plaintiffs and defendants has given me practical insight not often found in traditional resources. For dentists and their attorneys, the direction of a complaint or lawsuit may be shaped before the first patient interaction of the day. Drawing on four decades of successful dental practice ownership in New Jersey and Arizona, I share practical guidance to support sound judgment, effective office protocols, and a fulfilling dental career. This is not legal advice; it is common-sense guidance for building and sustaining professional success in dentistry.
Patient dental file requirements are similar in many states, but you should always confirm your State Board’s specific rules. Incomplete or missing documentation may violate statutes or regulations and can leave you exposed if a complaint or lawsuit arises. Even if a dentist successfully responds to a State Dental Board complaint, inadequate records can still create risk. In litigation, defending your position often begins with a subpoena for the patient's file, and weak documentation can seriously undermine your case. As the saying goes, if it is not in the patient’s dental record, it does not exist and did not happen. Do not let missing documentation create avoidable problems. Electronic dental records are now common, and most dental software allows appropriate notes and entries to be added directly to the patient file. Future blogs will offer practical shortcuts to make thorough documentation easier and to make it part of your daily routine.
Use my (unofficial) checklist to cross-check your operation and compliance:
Benjamin Berschler, DMD
Dental Expert Witness Services
Experience, Knowledge, Training, Certifications
Providing Objective Expert Opinions.
www.DentalExpertWitnessHelp.com
DentalExpertWitnessHelp@gmail.com
480-259-6952
Treatment and Clinical Records
• Welcome or introductory office forms
• Patient information and intake forms
• Signed medical and dental health histories, including updates
• HIPAA documents
Diagnostic Records
• all periodontal charting
• hygiene notes and treatment records
• all radiographs, with dates
• dated intraoral and extraoral photographs
• CBCT scans, including dated screenshots of key images, because the Board may not have software to open CBCT files
• CBCT radiology reports
Clinical Notes and Communications
• examination notes
· Missed-appointment records
• all clinical notes
· Journal entries
· Text message correspondence
· Conversations with front-desk and auxiliary staff
· Post-operative instructions
· Dismissal letters
· Refund information with release
Treatment Planning and Care Documents
• Treatment plans, whether signed or unsigned, proposed or accepted
• consent forms
• progress notes
• post-operative instructions
• prescriptions
• lab slips
• Outgoing referral slips
· Reports from treating specialists
• photographs of study models or digital models
• Invisalign or similar forms and correspondence
Anesthesia, Medical, and Records-Transfer Documents
· Anesthesia records, including patient weight
· Medications provided and current medication list
· Physician of record
· Medical clearance, if required
· Records-transfer requests with proof of completion
Financial Records
• Insurance claim forms
• Explanation of Benefits documents from all insurance carriers
• Complete ledgers
• Financial arrangements and agreements
• CareCredit or similar third-party financing applications and correspondence
• Cash receipts
· Missed-payment or stop-payment records
General Office and Correspondence Records
• Office notes
• Correspondence from any source, including letters, faxes, emails, and texts
• Patient encounter forms
• Records from other dentists or health-care providers
• Post-it notes or informal written notes
• Telephone logs and notes
Incident and Emergency Records
· State adverse-occurrence documents
· EMS documents
· General anesthesia documents
Benjamin Berschler, DMD
Dental Expert Witness Services
Experience, Knowledge, Training, Certifications
Providing Objective Expert Opinions.
www.DentalExpertWitnessHelp.com
DentalExpertWitnessHelp@gmail.com
480-259-6952
