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The Business of Dentistry: Patient Records and Record Management (AGD 550)

Presenter: Natalie Kaweckyj, LDA, RF, CDA, CDPMA, COMSA, COA, CPFDA, CRFDA, MADAA, BA, Contributing Authors: Wendy Frye-Agers, CDA, RDA, EFDA, MADAA; Linda Moan Charlton, CDA; Lisa Lovering; and Linette Schmitt, CDA, LDA, MADAA


Dentistry is a business as well as a health care service profession. It is essential to provide treatment for patients in a caring manner, but it is also necessary to maintain maximum efficiency and production in order to maintain a successful practice. The practice administrator plays a key role in the smooth operation of any dental practice, including the protection of patient information and records management. The knowledgeable practice administrator not only helps to increase office production but also assists the other dental team members in maintaining HIPAA and OSHA standards. This practice administration course focuses on several office and management responsibilities including the attainment of complete and accurate records and their legal ramifications with regards to risk management, storage and patient consent. The practice administrator must have a basic working knowledge of these procedures to maintain all office records.


has worked in the dental assisting profession as an administrator, a clinician, and an educator. She is currently a Licensed Dental Assistant in Restorative Functions, Certified Dental Assistant, Certified Dental Practice Management Administrator, Certified Oral & Maxillofacial Surgery Assistant, Certified Orthodontic Assistant, Certified Preventive Functions Assistant, Certified Restorative Functions Dental Assistant, and a Master of the American Dental Assistants Association, and holds several expanded function certificates. Natalie graduated from an ADA accredited dental assisting program at Concorde Career Institute and graduated with a BA in Biology and Psychology from Metropolitan State University. She is currently pursuing her Master’s in Public Health with a focus on epidemiology through Independence University.

Natalie has served in many capacities at the local and state levels of her state association, and is a past ADAA Secretary, Seventh District Trustee, ADAA President 2010-2011 and 2017 - 2018 and past Director to the ADAA Foundation. She is currently serving as President on the Professional Dental Assistants Education Foundation (PDAEF). In addition to her association duties, Natalie is very involved legislatively with her state board of dentistry and state legislature in the expansion of the dental assisting profession. She has authored several other courses on a wide variety of topics for the ADAA and is a speaker on dental topics locally and nationally.

Wendy Frye-Agers, CDA, RDA, EFDA, MADAA, currently lives in St. Louis, Missouri where she is a chairside expanded functions dental assistant for the St. Louis VA Medical Center. She is a Certified Dental Assistant, Registered Dental Assistant (in CA), Expanded Functions Dental Assistant and Master of the American Dental Assistants Association. Wendy graduated from the ADA accredited dental assisting program at Kirkwood Community College in Cedar Rapids, Iowa.  Wendy has been a CDA for more than 25 years and is a Life Member of the ADAA.

Wendy has served in many various capacities on the local and state levels of the Iowa, Missouri and California Dental Assisting Associations. She has also participated in the Missions of Mercy in Iowa and Missouri.

Linda Moan Charlton, CDA, lives in Billings, Montana. She is a Certified Dental Assistant, has ACLS certification and has been employed in the private practice of Michael W. Stuart, DDS until 2009 as a chairside assistant and is currently assisting in the practice of Will Winterholler. Linda began her dental assisting career as an on-the-job trained assistant and then challenged the CDA exam in 1999. Linda has served on the Executive Board of the Montana Dental Assistants Association, including the Presidency.

Lisa Lovering, is employed chairside in the private practice of Michael W. Stuart, DDS. Lisa began her dental assisting career as an on-the-job trained assistant. 

Lisa has served on the Montana Dental Assistants Association Executive Board, including the Presidency. She is a past Tenth District Trustee of the ADAA.

Linette Schmitt, CDA, LDA, MADAA, is a graduate from the ADA accredited dental assisting program at Hibbing Community College. Linette currently works as a chairside assistant in a large group practice. She is a Minnesota Licensed Dental Assistant and a Certified Dental Assistant, and is also certified to administer nitrous oxide analgesia. She is a Life Member of the American Dental Assistants Association and holds an ADAA Mastership.

She has served in many capacities at the local and state levels of her association, and previously served as ADAA Seventh District Trustee. Linette is legislatively involved with the Minnesota Board of Dentistry’s Policy Committee, and on several state committees.


At the completion of this course, the dental professional should be able to:
•Identify the components that make up a patient record.
•Describe SOAP and the portions of SOAP notes.
•Discuss all dental terminology associated with record keeping.
•Identify various charting symbols and interpretations.
•Identify the parts of a prescription.
•Define HIPAA.
•Describe what HIPAA requires.
•Identify three key areas covered by HIPAA.
•Discuss how protected health information can be recognized.
•Identify situations in which information can be disclosed without consent.
•Describe penalties for HIPAA noncompliance.
•Explain how to retain clinical records to meet legal requirements.
•Describe filing systems for practice income and expense records, patient financial records and account histories.
•Identify ways in which to protect records from hazards such as fire and water damage.
•Describe filing systems for other records such as recare/recall, laboratory prescriptions, personnel, radiation exposure and management records.
•Describe the standard of care in dentistry.
•Discuss the legal responsibilities of a dentist.
•Differentiate between act of omission and act of commission.
•Name three areas of risk management.
•Identify the greatest factor in preventing litigation.
•Explain implied consent.
•Discuss the situations that are exceptions to disclosure of information for informed consent.
•Understand the situations that require written consent from the patient.
•Identify the necessary information documentedwhen a patient is referred to a specialist.
•Monitor and respond to patient questions regarding insurance, scheduling and other non-clinical queries.
•Interpret and comprehend the Universal and Palmer numbering systems used in charting entries.
•Understand and reiterate basic terminology used in treatment plans and in describing dental procedures.
•Describe effective written communication techniques in preparing correspondence, electronic mail, reports and other documents.
•Discuss how to initiate and follow-up on procedures for the referral of patients to specialty practices.
•Understand the procedures relating to mail and other delivery systems.


The ADAA has an obligation to disseminate knowledge in the field of dentistry.  Sponsorship of a continuing education program by the ADAA does not necessarily imply endorsement of a particular philosophy, product or technique.

The ADAA cautions participants taking this course on the hazards of using limited knowledge when integrating new techniques into their practices.

Credits earned upon completion of the course may be used to meet DANB’s Recertification Requirements.


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