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Maintaining Proper Dental Records (AGD 550)

Presenter: Wilhemina R. Leeuw, MS, CDA


COURSE DESCRIPTIONMaintaining complete and accurate patient records is a sign of quality care and an integral part of our duty to care for the patient. Living in a highly litigious society, all health care professionals face the very real risk of being the target of a malpractice claim. As such, the dental profession must implement processes to minimize the risk of such actions. A properly documented record is the best defense against malpractice litigation, and every member of the dental team is equally responsible for recording pertinent facts about a patient’s visit on the chart and protecting vital patient information. This course provides dental healthcare professionals with the necessary background and procedures for proper charting and protection.

Although this course presents guidelines to minimize legal risks, it is for guidance purposes only and is not intended to be legal in nature. Legal counsel should be sought any time a practice decides to change and/or implement new forms, recordkeeping procedures or privacy safeguards.
An attorney will be able to inform and advise on the specific laws, rules and regulations that pertain to specific states and in specific situations.


Wilhemina R. Leeuw, MS, CDA is a Clinical Assistant Professor in the Department of Dental Education at Indiana University - Purdue University Fort Wayne, located in Fort Wayne, Indiana. A DANB Certified Dental Assistant since 1985, she worked in private practice over twelve years before beginning her teaching career. She received her Baccalaureate and  Master’s degrees in Organizational Leadership and Supervision from IPFW. She has authored for the American Dental Assistants Association and is currently serving as a CODA Accreditation site visitor. She is very active in her local and Indiana state dental assisting organizations. Her educational background includes dental assisting - both clinical and office management.


Upon completion of this course, the dental professional should be able to:

• understand the importance of and the reasons for properly documenting and maintaining patient records.
• differentiate between types of data that should be included or excluded from the complete record.
• explain ownership of the physical dental records, radiographs and information found in patient charts.
• avoid potential charting errors by learning to use objective and legible entries to properly document pertinent patient information.
• enumerate important criteria when recording treatment procedures.
• demonstrate how to properly revise an incorrect entry.
• explain the difference between a correction and an alteration of an entry in the patient chart.
• understand contributory actions and their necessary documentation.
• discuss the risks involved if documentation is inaccurate.
• gain a better understanding of dental malpractice, Standard of Care and the importance of communicating with patients.
• suggest ways to improve record documentation in the practice setting.
• understand the HIPAA privacy and security rules.


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 this course may be used to meet DANB’s Recertification Requirements.


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