The documentation obligation for dentists and what to consider

25. August 2022 | Regulatory, Information for dentists

What is the documentation obligation for dentists about? Which important points should I consider? What consequences should I expect if I do not comply with it and how can I make the documentation process in my practice as easy as possible? We will answer these questions for you in this article.

Obligations for dentists

The documentation obligation is only one of five basic obligations for dentists that are regulated by law. Other obligations in the medical area include the obligation to secrecy, the obligation to inform, the obligation to examine and treat, and (only to a limited extent for dentists) the obligation to visit. 

Thus, in addition to the treatment itself, dentists are obliged to document it carefully, in detail, and completely. In doing so, each patient record must be stored separately in the practice’s management system. The following must be documented in the process:

  • medical history
  • declaration of consent of the patient
  • treatment dates and times
  • diagnoses
  • patient education
  • particular difficulties in the treatment
  • treatment and cost plans

From a legal point of view, dental documentation is considered an official document and can be used in the event of a legal dispute. If no documentation is available, the situation is much more difficult. In this case, it is word against word without any basic evidence. Thus, the documentation obligation guarantees, among other things, that there is evidence in case of legal disputes. In addition, it ensures consistent treatment and serves as a basis for further medical treatments. If patients need to be referred to others doctors, the latter can access all the necessary information. The documentation is also the basis for any expert opinions and insurance inquiries.

How to make documentation easier for your practice

To best avoid any documentation errors, it is recommended to document the treatment either during or immediately after the appointment. However, the days when documentation had to be done by hand on a piece of paper are long gone—digitization is the keyword here. Modern software solutions for dental practices, such as infoskop® from synMedico, not only enable digital patient communication but also reduce your documentation workload. The patient admission process is also carried out digitally. For all of this, synMedico relies on the iPad®. During treatment, you can show the patient the treatment process as a video, call up consent forms, add notes to the X-ray image with the stylus, and much more. All of this is automatically documented for you by infoskop®. 

dentalXrai, our software for the fully automated analysis of X-ray images, also runs on iPads®. Detections are color-coded so that dentists can easily show and explain the findings to their patients. In addition, the software transfers the detections to an interactive digital tooth chart and automatically draws up a report. In this way, you can save yourself a considerable amount of documentation work.

synMedico’s “PA Cockpit” and dentalXrai’s “Parodont Pro” module go even further in recording and documenting periodontal bone resorption. With these new tools, the periodontal status of each tooth is automatically recorded and documented and it can be easily adjusted in the digital tooth chart. This reduces your workload considerably.

In summary, we can say that the documentation obligation for dentists is essential and accordingly unavoidable. To keep the workload as small as possible and to structure patient records as clearly as possible, we recommend digitizing the documentation process of your practice. Specialized software offers the optimal basis for this.

We look forward to introducing dentalXrai to you!

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  • Automated processes
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  • Color coded detections
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Susanne Brinkmann
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