Improving Documentation, Compliance, and Approvals in an Electronic Dental Record at a U.S. Dental School

Abstract

The aims of this study were to improve progress note documentation by dental students, achieve accurate and timely charge capture and treatment code and note approval, and determine the effectiveness of multiple interventions in improving overall documentation of patient encounters in the clinic of one U.S. dental school. The study, conducted in 2014-15, used a logic model to create a process to address documentation issues in the clinic's electronic dental record (EDR) and to assess the effectiveness of interventions. An initial documentation review using the EDR was performed to obtain a baseline measurement. A significant correlation was noted at baseline between poor documentation and unapproved treatment codes and notes. Unapproved treatment codes and corresponding documentation were then reviewed each month. Students who had the highest number of unapproved treatment codes were identified as potentially having documentation issues. These students were contacted and met individually with the associate quality and compliance officer to review documentation and charge practices. Large group education was also provided to key learners: dental students and supervising faculty members. Education consisted of an in-service event for faculty members and a Moodle site course on documentation for students. After one year, the results showed that documentation rates improved from an overall rate of 61% to 81% of required documentation elements being present in the progress note. Although this educational intervention was successful in significantly improving documentation of treatment in the EDR, 19% of the notes at the conclusion of the study were still missing key elements. Further research is necessary to determine whether the interventions will continue to improve documentation or if additional measures need to be taken.