Dental record documentation in selected ambulatory care facilities

Area of Science:

• Dental Public Health
• Health Services Research
• Healthcare Documentation

Background:

• Financial incentives differ for institutional providers and private practitioners in the Medicaid program.
• New York State Health Department implemented a streamlined prior approval process for 13 institutional dental providers.

Purpose of the Study:

• To evaluate the level of dental record documentation among institutional providers.
• To assess the impact of a corrective action plan on documentation quality.

Main Methods:

• Retrospective audit of 316 dental records from institutional providers.
• Follow-up audit conducted 3 months after implementing a plan to address identified deficiencies.

Main Results:

• Over 50% of facilities failed to provide all requested records initially.
• Most records lacked completeness, with deficiencies in intra-oral examination documentation.
• Follow-up audit showed statistically significant improvement in record documentation quality.

Conclusions:

• Initial performance in recordkeeping was inadequate despite agreed-upon procedures.
• Adequate dental records can be maintained with appropriate financial incentives.
• Retrospective evaluations relying on dental records require incentives for good recordkeeping.