Effective Date: June 10, 2013
Revision Dates: 5/1/2020, 3/1/2023
Background and Purpose
Occasionally, treatment documentation/notes are inadvertently entered under the incorrect patient or under the incorrect treating provider. While the School of Dentistry emphatically prohibits the sharing of logins and passwords (including axiUm swipe cards), it also recognizes that infrequent mistakes do occur. This policy clarifies when the deletion of treatment notes is appropriate.
The School of Dentistry prohibits partial and/or entire treatment documentation/note deletion except in the following circumstances:
The note to be deleted has not been used for any clinical decision-making
The documentation/note was entered under the incorrect patient/provider
Under exceptional circumstances, when approved by the Associate Dean of Clinics.
Documentation/note revisions and amendments are subject to the School of Dentistry’s “Amendment Policy for the Electronic Health Record”. Deleted notes are recorded in axiUm and if needed for audit, they can be recovered.
- Deletion requests will be forwarded to the School’s Associate Dean for Clinics for review.
- SOD-designated staff with deletion privileges will delete the documentation/note only if it meets the circumstances stated above.
- Comments are not entered into axiUm when deleting notes. Deleted notes are recorded in axiUm.
Exception: An addendum chart entry will be acceptable as long as no information identifying another patient is left in the note and the reason for deletion can be easily determined.
Dean of UWSOD:
Gary Farris, Assistant Dean, Finance & Administration
General Compliance Policies