Subject: Patient Record Management
Effective Date: December 2015
To establish uniform procedures detailing the responsibilities of dental providers (including Employee, Faculty, Affiliate Faculty, Pre-doctoral and Graduate Students) who administer treatment to patients of record within the School of Dentistry (herein referred to as “SOD”) to compile and maintain patient treatment records. This policy is intended to ensure that all patient recordkeeping is maintained by treatment providers at the SOD in a manner that is fully compliant with all relevant laws and regulations.
The SOD employs a patient Electronic Health Record (herein referred to as “EHR”) system called axiUm and a patient radiograph record system called “MiPACS.” Dental providers engaged in all levels of patient related clinical activity must adhere to strict policy guidelines and regulatory requirements when entering patient treatment notes and records in axiUm and MiPACS.
Such requirements also apply to approval of student notes and procedure codes compiled during clinical teaching activity. This policy sets forth: (1) rules for timely input and/or approval of patient treatment notes and procedure codes; (2) monitoring and corrective actions taken for non-compliant treatment providers; and (3) an enforcement mechanism – that will ensure that SOD remains in compliance with all applicable statutory and regulatory requirements.
I. Legal and regulatory requirements
Washington state law governing the “Maintenance and Retention of Records” requires that dentists compile and maintain comprehensive and dated patient treatment records. The statute expressly states that, “[any] dentist who treats patients in the State of Washington shall maintain complete treatment records regarding patients treated” (Washington Administrative Code (WAC) section 246-817-310). Furthermore, such treatment records, once compiled and recorded under the above provision, must be maintained in compliance with federal law governing confidentiality of patient records under the Health Insurance Portability and Accountability Act of 1996 (herein referred to as “HIPAA”). Under HIPAA and the SOD’s EHR policy, the obligation to ensure patient confidentiality extends to:
“…electronic exchange [of] financial and administrative transactions [for] health claims or equivalent encounter information; [such as] health claims… healthcare payment[s]… [including] unique health identifiers… [i.e. procedure] codes… for appropriate data elements for […] transactions… [including] audit trails in computerized record systems… (HIPAA Sec.1173 (a) “Standards to Enable Electronic Exchange”).”
II. Provider obligations
The following are the requirements adopted by the SOD, concerning the obligation of our providers to compile and maintain proper patient treatment records (regardless of whether the patient visit is considered a paid visit or a no-charge follow-up visit)
- Faculty – In recording treatment notes, faculty must utilize the SOAP format as stated in the SOD’s Health Information Management Policy, Section 3.1 of the Clinic Policy Manual for Faculty & Staff (herein referred to as Clinic Policy Manual). Notes must be completed, at the end of the treatment day or no later than twenty-four (24) hours following the patient appointment and in anticipation that the patient will be seen by other clinics and specialties for on-going treatment and/or for revenue cycle purposes. Please refer to the Clinic Policy manual for clarification and structure of SOAP notes. Furthermore, if scanning of patient notes, treatment plans or any other format containing information that cannot be captured in an axiUm form is used, there must be a separate fully structured and formatted SOAP note in the axiUm format within the above-mentioned time frame. In sum, all patient recordkeeping must be properly and promptly recorded in axiUm and/or MiPACS.
- Affiliate Faculty – Affiliate faculty must adopt the above-described policy utilizing the SOAP format but are required to complete and approve all treatment notes and procedure codes by the end of their assigned clinic session on the same day.
- Pre-doctoral, Graduate and Resident Students – Students engaged in patient clinical activity in a pre-doctoral, graduate, or resident program at the SOD must also follow the patient recordkeeping standards set forth in the Clinic Policy Manual. Students at all levels should complete their notes and input treatment codes by the end of their clinical session on the same day, for faculty approval. It is the student’s responsibility to obtain required faculty approval of their patient chart notes and procedure codes within the twenty-four (24) hour guideline. If a student has been monitored by an affiliate faculty member – he/she must get such notes and procedure codes approved by the end of the session.
- All SoD providers – Enforcement of Policy- Chart notes for Urgent Care Patients in 24 hours and for Routine Treatment at 7 days.
II. Training, communication and monitoring
A. Training & Communication
The SOD will reinforce training and support its providers in complying with treatment record requirements by:
- Creating and providing treatment providers with instructions on axiUm and MiPACS protocols for patient recordkeeping.
- Creating and providing hands-on training and reference materials for treatment providers on accepted practices of patient recordkeeping.
- Providing updates and/or refresher training to ensure compliance.
Monitoring will occur on two or more levels to quickly identify deficiencies and implement corrective measures before clinical processes interact with the revenue cycle process.
- “Front-line” verification to ensure that patient recordkeeping is completed and approved for processing through the revenue cycle will be conducted by:
- Clinic Floor Personnel – prior to the patient and treating provider going to the front desk and/or;
- Front Desk staff – upon check out with treating provider and/or;
- Clinic Manager – at the end of a session.
- axiUm reports will be generated on a weekly basis to ensure continual compliance and as an added layer of checks and balances with respect to:
- Lack of or missing treatment notes or procedure codes; and/or
- Unapproved procedure codes and notes; and/or
- Unacceptable standards or patient recordkeeping in axiUm (i.e. scanning or other form of recordkeeping not consistent with SoD standards)
- Timely Reporting of infractions: Report on-going deficiencies past seven (7) days but no later than fourteen (14) days to the Associate Dean for Clinics for appropriate action.
To ensure that the SOD remains in overall compliance with state regulations and licensing obligations, the following corrective actions shall be employed:
- First Warning: Written communication via email and/or letter informing treatment provider and the department; suspension of clinic privileges (including faculty practice activities) if the issue is not corrected within 2 weeks from the time of the procedure. If compliance is met within timeframe, no formal record will be placed in faculty file.
- Second Warning: Elevate infraction to Associate Dean for further action if not mitigated within thirty (30) days. A permanent record of infraction noted in treatment provider’s records; disciplinary action including, but not limited to suspension of faculty practice activities, a “non-meritorious behavior” citation, and further attention regarding performance of the faculty member.
Dean of UW SOD:
Joel Berg, Dean of the UW School of Dentistry
December 21, 2015
 Medicor Imaging Picture Archiving and Communication System – “MiPACS”
 See also Revised Code of Washington (“RCW”) § 18.32.655, Washington State registry (“WSR”) §§ 95-21-041 and WAC 246-817-340.
 See also RCW § 70.02
 http://www.hhs.gov/ocr/privacy/hipaa/administrative/statute/hipaastatutepdf.pdf ; accessed 05Oct2015.