KDA Today

KDA Today

For Immediate Release

Date: Feb 20th, 2015
Contact: Dr. John Thompson
Phone: 800-292-1855
Email: info@kyda.org

For the Record

It is New Year’s Day, again, and I am sitting at my desk with sunshine pouring in the window from a beautiful morning. Between a country ham breakfast and firing the grill for our traditional pork tenderloin, I am reflecting on my short-lived long term goals for 2014. I guess I will need to lose the weight I regained following the recycling of my hip parts. Getting older is so much easier with replacement parts as well as the perspective gained over the years, knowing that failing to accomplish resolutions allow those to be recycled as well for 2015.

There is one resolution that I would propose for our dental profession that is not new, but will have a new urgency in this coming year. That resolution would be that our dental records become real. Now before you react, let me clarify that this will be very easy for some of you who, might read this, but for a great many of us, who practice clinical dentistry, it might be one of those resolutions that will be recycled many times.

For the last several years, I have been reviewing casualty claims for a national company that provides opinions regarding orofacial/dental injuries that occur in all types of accidents. It is generally an interesting process that allows me to remain somewhat mentally attached to what is happening in clinical dentistry. This process involves a review of motor vehicle accident reports or incident reports provided by the police or claims investigators. It also involves the medical reports often submitted by

emergency room attendants and physicians or additional reports from other health care providers that may be attending to additional injuries. I will have to admit that in the almost two hundred claims that I have personally reviewed, the chiropractors have the longest and most detailed clinical notes and treatment plans I have ever seen.
Unquestionably, the worst clinical notes that I see on a regular basis are from the majority of dentists who become involved in these claims. That is, unless they are working with a lawyer on a direct referral and I can assure you that this does occur. Many dental casualty claims arrive with a beautiful narrative letter detailing information regarding the accident that precipitated the claim. These narratives often detail why certain treatment is necessary. The real problem occurs when this narrative is extrapolated from clinical records that bear no resemblance to the information in the submitted letter. The memory of the dentist is not supported by the legal clinical record. After many years of clinical experience I am often able to deduce what the records might indicate, but when you are providing this type of review it has to be, “just the facts”. The legal clinical record is what provides the facts for the diagnosis and clinical treatment and not a narrative written weeks or months after the event. It is the same standard that would apply to your records in a malpractice situation. A denial of what may be perceived as a legitimate claim because of deficient or nonexistent documentation of dental records does not make the patient or the dentist happy. I well, remember the mantra from every CE course involving malpractice issues, “If it is not in the notes, it didn’t happen.”

I will admit that my perspective is based on only on a few years of reviewing claims from the northeast and southeast. Because of my involvement with KYNECT and my recent time as your Interim Executive Director, I read quite a volume of information pertaining to public health policy and the Kentucky Medicaid program. Just a couple of weeks ago, Dr. Ken Rich, Kentucky Dental Medicaid Director, sent KDA leadership and me a record of the documented responses from state Dental Medicaid Directors regarding nationwide clinical dental records. This meeting took place on November 6, 2014 and the minutes of that meeting provide a wakeup call for practicing dentists, not just in our commonwealth.

The opening question was simply, “Have other state Medicaid and/or CHIP programs found that dental treatment documentation is a particular area of concern (e.g. a negative finding) as a result of the AUDITS in your state?” and the floodgates of reply opened. I will only share a few of the comments in this eight page record:
· “Because the documentation is so lacking, I also found it necessary to define what type of documentation is needed for our new regulations (yet to be published). Also the dentists (especially more established practitioners) keep documentations that is so sparse and not up even to the recommendations of practice management groups, liability groups…”

· “What is acceptable by the Board of Dentistry may or may not be acceptable by the auditors and what is acceptable by the auditors may not be acceptable in a court of law.”

· “As one auditor said in a meeting, ‘I can put most of the offices in the state out of business if you want me to, but this is not fraud it’s mostly just minor compliance issues’”.

· “Issues like not signing chart entries, not documenting that a service that was billed for was even rendered.”

I did take heart that one particular comment did offer a palatable solution that I and we should readily accept. “Engage the American Dental Association to first determine what constitutes appropriate documentation. The ADA will then need to enlist the support of each state dental association to provide further feedback/refinement. Then CMS can promulgate standards to all states - and the consensus will essentially be in place.”

This is a real problem that we can fix by simply writing down why and what we are doing as if we had a partner and staff that will see our patient while we are on vacation. We all learned, early in dental school, what progress notes were supposed to look like and most of us looked for every way possible to simplify that process. That simplification has truly gone too far for many of us. If we don’t improve the quality of clinical communication, we are going to be told by federal and state regulators exactly what has to be written in order to expect to be paid or protected in courts. The profession must write the guidelines for our inter-professional correspondence that is required to meet the meaningful use standards or there will be new regulations (yet to be published).

We know that diagnostic codes are coming. We know our records will be more or less integrated into the medical records of our patients. We know there are going to be audits by both Medicaid and third party payers. We know that today’s society is the most litigious in history. We know we can do a better job of writing clear clinical notes that are an actual readable history of why and what we provide as dental care for our patients. For over forty years I had practice partners who saw my patients when I was away and I saw theirs. We were essentially writing notes to each other (inter-professional communication). In those forty-plus years, notes to my partners made one Board of Dentistry and two records subpoenas go completely away. Today, I would have to make the same New Year’s resolution you should make, in that my records will provide the information that meets the new standards that we are writing. I well know that we don’t like outside regulation that tells us how to practice this profession. There is no question that health care has changed and we still have a chance to adapt ourselves and eliminate the glaring deficiencies in our record keeping.

For the record, if I were still practicing, I would never have written this commentary. It is much easier to see this problem as an observer or as a reviewer, because while I was practicing dentistry I always knew exactly why I did something and what I did and my memory was such that I could always fill in the blanks if necessary…that is, unless I forgot. I hope you are having a good day and will have a great 2015, but make one resolution that in the future, might just save your A_ _!

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