4 Easy Steps to Audit a Patient’s Chart

April 30, 2024

Filed under: Uncategorized — dentalsupportteam @ 4:28 pm
dental front desk team member smiling at a patient

A patient is dissatisfied with their treatment and decides to sue you, but you can breathe somewhat easily because you know your patient records and charts are thorough and accurate. You’ve had chart audits done and have learned to be meticulous in your record keeping.

No dentist wants to find themselves in this kind of scenario, but it can happen unfortunately. Chart auditing is a great way to ensure the quality of your records as well as have a clear picture of how your practice is doing financially. But how can you audit a patient chart and make the process as smooth as possible? Here are important, yet sometimes overlooked, steps to follow!

Step 1: Make Sure All Notes Are Clear for Third Parties

At some point, your records and claims will be read by someone outside of your office, whether it’s a litigant or an insurance company. The language used to describe diagnoses and treatments needs to be crystal clear, precise, and thorough so that anyone will be able to know exactly what was done and why it was necessary.

Step 2: Make Sure Necessary Documentation Is Attached

Even though notes on records can be valuable, documentation can back up your claims and findings. If a picture is worth a thousand words, then you should definitely include X-rays, images captured by an intraoral camera, and other documents to speak up for you! Other documentation includes verified insurance information, forms that the patient has signed, and any impressions or virtual designs created for them. This evidence can substantiate claims to insurance or enable you to defend yourself from a lawsuit.

Step 3: Look for Patterns of Poor Documentation

No one is perfect, so don’t be surprised to find errors here and there. However, while you’re chart auditing, keep an eye out for repeated mistakes. If they indicate a larger issue or pattern, it’ll need to be corrected to prevent future charts and records from being inaccurate or incomplete.

Step 4: Don’t Let Patients Fall Through the Cracks

Part of chart auditing is determining how many and which patients are overdue for an appointment or have incomplete treatment. Identifying these people can help you direct your time and attention to those who may be on the fence with a certain procedure or to those who have forgotten about your practice. As a result, chart auditing can give you opportunities to bring in more revenue.

Chart auditing entails a long list of things to look for and steps to take, but if you follow these less-known steps, you can cover your bases in case you are ever sued or if insurance pushes back on a claim.

About Dental Support Specialties

Dental Support Specialties is proud to be HIPAA compliant and has helped dental practices with chart auditing for over 15 years now. Our team exclusively works in the dental field, which means we are familiar with what insurance companies and other entities are looking for in charts and records. If you would like to discuss your chart auditing needs with us, just reach out to our team online for a consultation.

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