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The comprehensive case note: Your number-one defense witness

Feb. 16, 2023
The 12 components of a comprehensive case note will go a long way in defending you from litigious patients or disciplinary action from state dental boards. Here's what to know.

The case note is arguably the most important component of a complete dental treatment record. If drafted correctly, case notes are your best evidence that you have complied with standards of care. Conversely, poorly written or incomplete case notes can be a source of legal jeopardy and embarrassment.

The case note, also known as the progress note, serves to chronologically document patient encounters, communications, and dental procedures. Along with the other components of a complete dental record, the properly written case note serves as a legal, business, administrative, and medical entry that documents and justifies treatment decisions that defend the provider from litigious patients or disciplinary action from state dental boards.

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Always remember that your case notes may be scrutinized by lawyers, licensing boards, judges, juries, insurance companies, and your patients. Your case notes should stand on their own, meaning that any dentist not familiar with your patient will understand what you did and why it was done. Third-party reviewers of dental treatment records are not mind readers. The general rule is that if it isn’t written in the record, it did not occur. A properly written case note allows the reviewing dentist to independently follow your treatment decision-making logic.

No consistent statewide requirements

Who determines the essential elements of a properly written case note, and where do we find them? Certainly an important question … with no simple answer.

Most state dental board regulations make reference to a dentist’s duty to maintain complete treatment records. The problem is lack of consistency throughout the country as to a clear outline of mandated case note entries. Some states provide detailed case note requirements, some provide minimal guidance, yet all states will discipline a dentist if insufficient records are before them when evaluating patient complaints.

Good sources and examples of properly written case notes can be found at risk management departments of professional liability insurance carriers, the American Dental Association, and in various texts and journal articles.

While reviewing these resources, I have found that there are 12 essential components (sidebar) that many sources have in common. If you wish to maximize your legal protection, include these 12 components in each case note, and your documentation will be in compliance wherever you practice.

Although some of the documentation may be entered elsewhere in the dental treatment record, if you follow these guidelines, you will have a case note that is a complete and thorough record of your patient contact. The rationale supporting your patient-care decisions will be clear and justified by your documentation. Your note will stand on its own and be understood by independent third-party reviewers. You will have created your “number-one defense witness.”

The 12 essential components of a case note

  1. Chief complaint
  2. Objective findings
  3. Assessment and diagnosis
  4. Treatment plan
  5. Medical and dental histories
  6. Informed consent/informed refusal
  7. Treatment performed
  8. Medication administered/prescribed
  9. Patient reaction
  10. Patient instructions
  11. Plans for next visit
  12. Provider signature and date

I recommend beginning your case note with the chief complaint, your patient’s reason for visiting your office. Did the patient present to your office with a specific dental issue or as a preplanned visit as part of an existing treatment plan? Is your patient complaining of facial swelling, a toothache, a loose crown, or simply there for a previously planned procedure? In effect, you are telling a story about why your patient is in your dental chair and what happened. This is where you include your patient’s subjective comments about what they are experiencing.

Next, detail your objective findings in your record of examination, including caries, tooth fracture, swelling, bleeding gums, periodontal pocket depths, radiographic findings, mobility, oral cancer screening, etc.

These documented findings set the stage for the next section of your case note: assessment and diagnosis. Based on your clinical and radiographic findings and your patient’s subjective comments, you will render a diagnosis, or at the very least, a differential diagnosis. If you had not included your objective findings prior to your assessment and diagnosis, you will leave any third-party record reviewer scratching their head as to how you came to your conclusions.

What is your treatment plan for that specific patient visit? The treatment you provide on that visit may have been developed on the spot or may already be part of an existing treatment plan. Even if you have a comprehensive treatment plan elsewhere in the patient record, include the plan for that day’s visit in your case note.

Medical and dental histories: Comprehensive medical histories should be updated at least every two years and signed by both the patient and the dentist. Every visit thereafter, without exception, requires a documented review of medical history. Have there been any changes in the patient’s medical history since you saw them last? Have they developed a new medical problem? Are they on new medications—prescription or over-the-counter?

If the patient is presenting for a previously treatment-planned procedure, have there been any changes since your original diagnosis? Has the tooth fractured? Has it become symptomatic? If so, you will want to enter your new findings, which may or may not require a modification of your existing plan.

Informed consent/informed refusal requirements vary depending on the nature of the procedure you recommend or perform. All major procedures involving surgery, removal of significant amounts of tooth structure, endodontics, or prosthetics should have a separately signed informed consent in the patient record.

Even if the patient has signed the informed consent form previously, I recommend an entry into the case note that you reviewed the informed consent. Include all noncompliance issues including refusal of treatment and potential consequences. Simple restorations, examinations, and x-rays generally do not require a separate informed consent; an entry into the case note that informed consent has been obtained will suffice.

Treatment performed is the next aspect of the comprehensive case note. It is not necessary to include every detail of each procedure. A brief description will often suffice, but be sure to include all materials used in the patient’s mouth.

Medication prescribed: Accurately document the exact number of carpules and type of local anesthetic administered. Be specific as to the name and dosage of local anesthetic and epinephrine and route of administration. All medications prescribed, prescription and nonprescription, should be documented with dosages, frequency, and duration.

Note the patient reaction to the procedure. Did your patient tolerate the procedure well? Did you have difficulty obtaining local anesthesia? Was there a miscommunication with the patient, and how was it resolved? Hopefully most of your entries will state that the patient tolerated the procedure well, but we all have experienced unexpected results during patient visits. Document patient compliance issues such as failure to follow instructions or keep appointments.

Patient instructions include your pre- and postprocedure instructions with follow-up plans. If you provide written instructions, it is sufficient to indicate that you have provided and reviewed these with your patient. Patient instructions also refer to recommendations you have made to your patient such as new treatment recommendations and referrals to specialists.

Plans for next visit: Document your plans and recommendations for subsequent treatment or follow-up. Memories fade over time; patients get distracted and may not return as prescribed. This can also be a big help to your staff in scheduling and preparing for your patient’s return visit.

Provider signature and date: Initialing case notes is no longer acceptable. Full signature and date are now required by many dental boards. Your patient’s name or identification number should be included at the top of every page of the record. You never know where your records may end up. Review of patient records can sometimes be confusing, especially when patients have had multiple providers.

Conclusion

Although my recommendations will result in some duplication of effort between your case note and the body of your patient record, a thorough stand-alone case note goes a long way in defending you against claims. Keep your comments objective in tone and factual. Never enter disparaging or personal comments into your notes as such remarks may be viewed by juries, judges, dental board members, your patients, or their legal representatives.

Avoid overuse of electronic record “copy and paste” templates and uncommon abbreviations. Edit, delete, or add information, and make certain your notes accurately reflect your unique and individualized patient encounter. Strive to complete your case notes immediately after each patient visit or at least by the end of the day, and remember to note all patient phone calls and emails.

Finally, should you realize you have made an entry error or omission, don’t panic. Simply create another note with the current date, and enter your corrections or omissions. Never change or modify the original entry; such efforts may be viewed as an attempt to alter the record for self-serving purposes. 

Editor's note: This article appeared in the February 2023 print edition of Dental Economics magazine. Dentists in North America are eligible for a complimentary print subscription. Sign up here.

About the Author

Richard S. Harold, DMD, JD

Richard S. Harold, DMD, JD, is an adjunct professor at Tufts University School of Dental Medicine in Boston. Dr. Harold received his DMD degree from Tufts University, his JD from New England School of Law, and his BS in pharmacy from Massachusetts College of Pharmacy. Prior to joining the faculty at Tufts University, Dr. Harold owned and operated a general dentistry practice. Dr. Harold has a specific interest in dental-legal issues and has lectured locally and nationally.

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