Frequently Asked Questions

Have a question about a pressing risk management issue? Our experienced Risk Management analysts have answers. From treating minors to retaining patient records to employee leaves of absence, chances are, your question has been asked before. The following is a list of frequently asked questions, along with practical solutions, that can help you avoid liability within your practice.

When patients ask for their records, do I need to give them everything in their chart since they started coming to my office?

Record Keeping

Complete patient records include the following:

  • A description of the patient's original condition
  • Your diagnosis and treatment plan
  • Progress notes on the treatment performed and the results of that treatment
  • Patient's personal and financial information
  • Health history (all questions answered) and regular updates
  • Dental history
  • Vital and diagnostic signs
  • Oral cancer screening
  • TMJ evaluation
  • Periodontal evaluation
  • Diagnostic test findings and exam notes
  • Consultant reports, reports to and from specialists and physicians
  • Notes describing complaints or confrontations
  • Notes about rescheduled, missed or canceled appointments
  • Exam notes and treatment notes
  • Informed consent discussions and forms
  • All radiographs taken at intervals appropriate to patient's condition
  • Correspondence to and from the patient inclusive of phone calls, emails, voice messages, letters and face-to-face conversations
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The suggestions provided represent experience and opinions of TDIC. There are no guarantees that any particular idea or suggestion will work in every situation. The ideas and suggestions contained in this document are not legal opinion and should not be relied upon as a substitute for legal advice. For legal advice specific to your practice, you must consult an attorney. 

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