Subject: Health Information Management
Effective Date: January 1994
Review Dates: June 2014, January 2016
To assure accurate documentation of care, referrals and consultations, correspondence related to care and to provide a legal and risk management support document for the University and the School of Dentistry.
axiUm is the UW School of Dentistry’s (UWSoD) comprehensive clinic management system that was implemented in July 2009. Together with MiPacs digital radiography which was launched in July 2011, it forms the backbone of the Health Information Management system. axiUm’s main functions include electronic health records, patient billing and insurance.
Privacy of patient records is protected by state confidentiality law and the records themselves are the property of the University of Washington School of Dentistry. The Associate Dean of Clinical Services or designee is the official record custodian for the school and Patient Services assigns patients to the appropriate care provider during care and consultation activities.
Storage and tracking protocols must be followed by anyone who uses or has access to patient records.
The content of the record must conform to the approved configuration and entries must comply with a standardized format.
A. Ownership and contents
Clinical records include the patient chart and its contents, radiographs, laboratory, and other prescriptions, study models, and patient photographs. All original copies of records are the property of the University of Washington and shall remain on the premises unless requested under subpoena. A duplicate record shall be made and retained in these circumstances.
B. Access and Security
Access to the axiUm resources can be both on-site and through remote access.
The user of the UWSoD axiUm resources must comply with UWSoD policies, which in turn must comply with federal and state statutory and regulatory requirements. The user has the responsibility to protect access accounts, privileges, and associated passwords. The user must maintain the confidentiality of information to which he/she is given access privileges, and accept accountability for all activities associated with the use of his/her individual user accounts and related access privileges. Failure to comply with the above Privacy, Confidentiality, and Data Information Security Agreement may result in disciplinary action up to and including denial of access to information and suspension from school and/or termination of employment at the UWSoD.
C. Record Review
The Office of Clinical Services (OCS) shall be responsible for record review as defined in Section 5-1 b. of the ADA’s Accreditation Standards for Dental Education Programs (below):
Standard 5-1 b. THE DENTAL SCHOOL MUST CONDUCT A FORMAL SYSTEM OF QUALITY ASSURANCE FOR THE PATIENT CARE PROGRAM THAT DEMONSTRATES EVIDENCE OF: b. AN ONGOING REVIEW OF A REPRESENTATIVE SAMPLE OF PATIENTS AND PATIENT RECORDS TO ASSESS THE APPROPRIATENESS, NECESSITY AND QUALITY OF CARE PROVIDED.
D. Record Keeping and Progress Notes in axiUm
Patient records are an essential component of the delivery of competent and quality oral health care. All record must be authentic, accurate and objective. At each patient visit, the health history should be consulted and updated.
UWSoD is employing a standardized format, SOAP, for treatment notes. As a guideline, for patients seen on an emergency basis, axiUm notes should be entered at the end of the treatment day or no later than 24 hours in anticipation that the patient will be seen by other clinics and specialties for on-going treatment. In general, progress notes for regular treatment should be entered and approved no later than 7 days from the date of providing service.
E. Confidentiality and Release of Information
Patient records are protected by Washington state confidentiality law (see RCW 70.02, www.leg.wa.gov/rcw) and the federal Health Insurance Portability and Accountability Act (HIPAA). Access to patient records is limited to students, faculty, and staff who are involved with the patient’s treatment. Discussion about a patient shall be limited to issues related to their care and shall not be conducted so that inappropriate individuals could overhear.
Release of required information for third party carriers reimbursement shall be documented via signed patient authorization on the registration form.
Patient records used for research purposes are subject to state law as well as to the Human Subjects Policy of the University of Washington. Permission to view records of the general patient population for purposes of screening for research subjects, or to conduct research using patient records must be obtained from the Clinic Director and from Human Subjects Division and/or the Institutional Review Board. Records for clinical research subjects are to be kept in the clinical research center (RCDRC) and managed by the director of the center in accordance with state law.
Patients have a right to obtain a copy of their record and a reasonable charge may be assessed for the service as outlined in the state law. Request for duplication of records must accompany a signed Patient Authorization for UW School of Dentistry to Disclose/Release Protected Health Information form (see Appendix A). Duplication of requests shall be submitted to and prepared by the Patient Records staff. All attorney requests for records shall be reviewed by the Manager of Patient Services prior to release.
Patients may view their record upon request by appointment during normal working hours.
Grading information, administrative correspondence, incident reports, visit slips, and departmental memoranda are NOT part of the patient’s record, therefore shall not be stored in the patient record nor should be released unless subpoenaed.
All employees, students and volunteers who are involved in patient care or have access to records are required annually to read and sign a Privacy, Confidentiality and Data Security Agreement (see Appendix B).
F. Archival Protocols
Both the state and federal governments have laws on healthcare record retention, but the federal law supersedes the state law. The Health Insurance Portability and Accountability Act (HIPAA) requires that all dental records be kept for at least six years after the patient’s last visit.
In accordance with University archival policy, records shall be retained on the premises for inactive comprehensive care adult patients for six years. Subsequently, they shall be transferred to University Records Center for the remainder of a 35-year retention period.
Records for pediatric patients follow the same protocol for up to 35 years. Records for limited care patients deemed to be of no research value are retained for up to 8 years following the completion of care.
II. Registration and Record Format
An electronic health record shall be created for all patients seen at the School of Dentistry. A permanent account number will be assigned to each patient record once the patient has completed the registration process which includes entering patient demographics, financial information and signing all consent forms.
All patients who receive care in the student clinics, including WREB patients, shall be registered as patients with the School of Dentistry.
B. Chart Contents
Patient radiographs are stored in the MiPacs system which is linked to axiUm. All radiographs must be prescribed and approved by the supervising faculty member. A unapproved image report will be run by the OCS on a regular basis to urge the care provider to obtain approval. Clinical privilege may be suspended for serious offenders.
In the same manner, patient clinical photographs may be stored either linked to axiUm or in school approved servers. To re-emphasize, all original copies of radiograph and photographic records are the property of the University of Washington and can only be released with the consent of the patient and with school’s approval.
Only forms approved by the Clinical Services Committee may be added to a record. Items in a record shall be limited to authorized contents as specified above.
C. Chart Assignment
Access to the patient record is given to predoctoral students by the Patient Services staff.
Patient reassignment, discontinuance of care, and inactivation are changes in a patient’s assignment status which is determined by the Patient Services staff and the Manager of Patient based on disposition information contained in the record. Such a change in status shall be managed by the OCS. Students shall not “trade” patients or transfer their care without approval from either the faculty advisor, or from the Patient Services staff.
Upon graduation, the student must complete a audit of all assigned patients with their assigned Patient Care Coordinator. The student shall make a status of care entry in the treatment notes.
D. Dental Recordkeeping
The care provider shall document all significant patient communication in contact notes, as well as diagnostic and treatment services in the treatment history. Radiographs, photographs, consultations, and correspondence relating to patient care shall be retained in the patient record.
A medical history form shall be completed in axiUm for every patient prior to initiating care. It shall be electronically signed by the patient. The medical and dental history form shall be updated formally in axiUm for all patients annually. Medical alerts will populate in the “alerts” in axiUm when an adverse health condition is entered into the medical and dental history from.
Patients who are under active treatment shall be asked about their health status at every visit. Such informal inquiries about changes in health status shall be documented in the treatment notes and must update the medical and dental history form.
E. Treatment Plans
A current treatment plan and signed patient consent is required for all comprehensive care patients. Diagnostic and emergency services may be rendered during the development of a treatment plan; however, consent must be obtained and documented in the progress notes in these circumstances.
The student is responsible for the preparation of treatment plans for their assigned patients and may lose credit even if faculty supervise care without a treatment plan.
F. Progress/Treatment Notes
All appointments shall be scheduled in axiUm, including canceled and broken appointments. Progress/treatment notes must be entered by the care provider and properly approved/swiped by the supervising faculty member. Progress/Treatment notes shall be written using the SOAP format and shall include the date, department where treatment is rendered, teeth, and surfaces treated (or area of the mouth treated), and the body of the note. The body includes the diagnosis, the treatment (including materials used and their brand names), medications prescribed (including anesthetic used), post-operative instructions, and next visit plans. Sample Progress/Treatment notes of properly entered treatment notes notes using the SOAP format can be found in the Appendix (See Appendix C.)
Standardized abbreviations shall be used for writing progress notes in order ot save space and expedite chart entries and NC may be written after each of the SOAP segments in the entry to indicate there was no change from the previous visit (see Appendix D).
G. Amendments and Deletions
Correction to a treatment note or a late entry must be entered with the current date and must include the reason for the addendum or correction. Guidelines for amending and deleting notes can be found in the Amendment Policy for the Electronic Health Record (see Appendix E.)
The SoD prohibits deletion of treatment notes in axiUm except if the note was entered under the incorrect patient or a note was entered under the incorrect treating provider. Deleted notes are recorded in axiUm and can be recovered. The protocol for deleting notes in axiUm can be found in the Deleting Treatment Notes in axiUm policy (see Appendix F.)
H. Notice of Privacy Practices
Consistent with federal law, the UW School of Dentistry provides each new patient with a copy of its Notice of Privacy Practices, or, at a minimum, offers it to them at their initial visit and makes it available hard copy or electronically. The Notice includes contact information and detailed instructions on how patients can exercise their privacy rights.
The UW SoD has several photo releases for specific scenarios. These photo releases authorize the SoD to disclose photographs of patients or students for a variety of purposes.
Appendix A, Patient Authorization for UW School of Dentistry to Disclose/Release Protected Health Information
Appendix B, Privacy, Confidentiality and Data Security Agreement
Appendix C, Sample Progress/Treatment Notes, SOAP Format
Appendix D, Standard Abbreviations
Appendix E, Amendment Policy for the Electronic Health Record
Appendix F, Deleting Treatment Notes in axiUm policy
Appendix G, Notice of Privacy Practices
Appendix H, Photo Releases
Dean of UW SOD:
Joel Berg, Dean of the UW School of Dentistry
February 2, 2016
Sample Progress/Treatment Notes
Patient has no orofacial complaints. Presents for comprehensive exam, treatment and plan, and dental prophylaxis.
Vital Signs: BP 120/84 HR:62 P:__ TEMP:__ Head and Neck:__ Intraoral__ Periodontal:__ Dentition:__ XRAY:__
- generalized gingivitis 2. dental caries.
Med hx and radiographs rev’d, medications updated, pt took 600mg clindamycin 1 h prior to dental tx for__. Intra- and extra-oral exam; perio charting; 4 BW’s;; OHI, prophy. Rx-Prescription-items dispensed: Soft toothbrush and floss, clindamycin 300mg x 8 tabs: take 600mg 1 h prior to dental appts [indication?]. Next visit: Pt to rtc for restorative tx #12, referral to radiology for pan; 6 mo recall.
SOAP notes are usually used AFTER the initial visit for followup visits, so if this is the first visit, it probably would not be exactly relevant and applied. The main conceptual shift is to always check if patients have any complaints and always list their current problems and diagnoses. The plan always follows each problem and each diagnosis of the problem. This is a sea-change for many in dentistry but it can help avoid many problems with diagnosis. Using subheadings within the Plan is common, such as next visit (NV and prescription as RX). Some in our service like to start with the known problem, so it can be revised as P-SOAP for return visit, which is similar to PARTS.
|Am||Amalgam (Insert brand used)||OHI||Oral Hygiene Instruction|
|B||Base (Insert type used)||PFM||Porcelain Fused to Metal|
|C||Composite (Insert brand used)||POI||Post Operative Instructions|
|C/R ratio||Crown-root ratio||Prep||Preparation|
|DR||Defective Restoration||PSA||Posterior Superior Alveolar|
|FT||Fractured Tooth||RCT||Root Canal Therapy|
|FGC||Full Gold Crown||RD||Rubber Dam|
|GI||Glass Ionomer||ReCar||Recurrent Caries|
|HH||Health History||Rt. Car||Root Caries|
|IC||Incipient Caries||Rt. Prox.||Root Proximity|
|INF||Infiltration||S & RP||Scaling and Root Planing|
|LB||Long Buccal||SSC||Stainless Steel Crown|
|MGJ||Mucogingival Junction||V||Cavity Varnish|
|NV||Next Visit||ZOE||Zinc Oxide Eugenol|