Dental Patient Chart Audit Checklist

Chart audits provide an effective way of determining if steps such as recording blood pressure readings and taking an adequate number of radiographs have been followed correctly. They also assess whether all instruments and handpieces have been stored safely and that a log has been kept of drugs and syringes distributed.

Checklist 1: Patient History
Dental patients typically fill out patient health history forms at their initial visits, providing practitioners with vital information regarding allergies, medical conditions and any relevant details. This information helps practitioners better serve patients.

Dental hygienists and dentists record appointment details such as time, date, location and quality of care provided to their patients in an electronic health record system maintained by the clinic. This data is meticulously kept on file at each visit.

These records may be subjected to both prospective and retrospective audits with the purpose of verifying that only completed work is billed, while claims submitted accurately. Such audits necessitate using audit tools that separate collected data for easier tabulation of results.

Checklist 2: Exam
Exam section of a chart audit involves reviewing both subjective and objective information regarding oral health of patients, such as soft tissue evaluation and intraoral inspection for signs of plaque, gingivitis or tooth surfaces.

Audits of dental patient charts are performed to ensure that offices meet state or insurance company guidelines, detect billing/coding/documentation errors and to identify areas in need of improvement within their practice. Annual reviews can also help identify opportunities to strengthen operations.

If a practice is up for sale, buyers will study its charts to ascertain its treatment philosophy and procedures as well as examine its fee schedule and appointment book.

Checklist 3: Hygiene
Dental patient chart audits may make family physicians uneasy as the notion of federal investigators or insurance company representatives entering their offices to look for any indications of wrongdoing arises in their mind. But in actuality, a chart review’s purpose is simply to evaluate and improve practices at your practice.

An effective hygiene audit includes more than reviewing the appointment book; it should also assess how many active returning patients have been pre-appointed for cleanings, what percentage of operatory schedule is booked and if there are any gaps in production schedule. In doing this, a thorough hygiene audit also serves as a financial due diligence exercise, providing insight into future business potential of your practice.

Checklist 4: Radiographs
At each dental visit, a lot happens: your hygienist cleans and checks for cavities; the dentist performs an exam; and X-rays are taken to ensure there are no hidden damage or disease. All these steps are recorded carefully in your digital chart.

Step one is identifying an agreed’standard’ against which to compare current practices, whether that be nationally recognised recommendations, regulatory agency standards or local agreed criteria.

Once you have identified the criteria you will use to select an audit sample and have collected your data manually or electronically (using an Excel sheet), automatically calculate rates, percentages or means automatically.

Checklist 5: Surgical Procedures
When patients visit their dentist and hygienist, more work than simply teeth cleaning takes place. Dental exams, checks for gum disease and oral cancer, referrals made as needed and document procedures performed are performed and meticulously recorded in the patient chart.

Insurance companies frequently select samples of charts for audit by insurance carriers to assess compliance with coding, billing and documentation requirements. Retrospective chart audits may reveal overpayments which must be disclosed or returned by practices.

Conducting regular clinical chart reviews can reduce the number of inaccurate claims submitted by your practice, while creating simple audit tools can enable nonclinical staff to perform these reviews effectively.

Checklist 6: Treatment Plan
Chart audits can be both clinical and administrative studies. An audit involves setting standards, collecting data to compare existing practice with these standards, and making changes as needed. For instance, a clinic could conduct such an audit to see how often certain vaccines are offered or given out so as to meet medical protocols.

An administrative chart audit involves reviewing practice management software and fee schedule, in addition to reviewing an appointment book sample from a seller’s practices in order to help buyers assess whether their practices have potential to meet revenue goals; it also serves as a paper trail should malpractice claims arise against them.