Record Keeping Course
Self-Study

Record Keeping Basics / Self-Study Format
Carol Tekavec CDA RDH

This self-study course details recommended documentation techniques for adequate record keeping. Appropriate record keeping is vital for supporting diagnostic and treatment decisions, as well as to prevent payment problems with dental benefit plans. Malpractice and adverse insurance company "utilization review" problems can be mediated with adequate and detailed records. Learn what a proper record must contain to be considered adequate.

This self-study program may be appropriate for dentists and/or staff who are being required to complete a record keeping course. Problems with record keeping continue to be common with State Dental Boards. Dentists facing Board sanctions often have issues of inadequate record keeping and documentation. In addition, financial/insurance disputes with patients often hinge on records.

While many State Dental Boards require that dentists with record keeping issues attend a course on record keeping, few such courses are offered. A self-study program may fulfill the requirement.

Course topics:

• Documenting medical and dental histories

• Record keeping for initial data collection

• Documentation of a treatment plan

• Guidelines for informed consent and progress notes

• Process of Care Evaluation Measures guidelines (Evaluation of a patient record)

• Guidelines for prescribing dental radiographs

• HIPAA basics, including "Notice of Privacy Practices" and Acknowledgement of Privacy Practices

Course materials:

• Record Keeping Basics - Printed Power Point booklet

• Complete sample - adequate record - "The First Encounter" chart; including 15 forms and chart folder

• Complete 28-page instruction manual for "The First Encounter" chart

• Informed Consent Booklet of 26 individual procedure, reproducible forms.

• Process of Care Evaluation Measures guidelines (Evaluation of a patient record) developed cooperatively by the California Dental Association, California Association of Dental Plans, and Delta Dental of California. Guidelines format designed by Dr. D.E. Fitzgerald.

• Guidelines for Prescribing Dental Radiographs - developed by Eastman Kodak in cooperation with the FDA, AGD, AADR, AAOM, AAPD, AAP, and ADA.

• Self-Test

A written confirmation from the author, verifying the date the course was ordered, accompanies the self-study materials. No continuing education credits are available. A similar program in a non-self study format is offered by the author for the ADA Seminar Series, however, this self-study course in not that program.

Course Author:

Carol D. Tekavec CDA RDH is a well-known author and lecturer on practice management topics. She has presented programs nationally, internationally, and on videotape. She currently offers a course for the American Dental Association Seminar Series, "Update on Record Keeping and Insurance". She is the designer of a popular dental chart, the First Encounter, author of the insurance reference manual, the Dental Insurance Coding Handbook (which is updated for each ADA code revision), and has developed many other practice systems and formats, including an Informed Consent booklet in English and Spanish, a Dental Office Letters book, and basic HIPAA forms. She is the columnist on insurance for Dental Economics magazine since 1995 and has authored over 100 magazine and journal articles.

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