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Dental administrative assistants perform a range of duties for dental practices to ensure their smooth and responsible operation. Dental administrative assistants are skilled in understanding the procedures and protocols involved in the day to day operations of dental offices, including scheduling appointments, filing, and record-keeping. Record-keeping is a particularly important part of the job of a dental administrative assistant, as dental records are essential to the job of any dentist. Dental records contain information which ensures that clients are receiving proper dental care and fulfills the ethical and legal obligations of the dentist. 

Because dental records are legal documents, proper record-keeping practices are vital to maintaining a responsible practice and keeping clients safe. Aspiring dental administrative assistants can find the province of Alberta’s complete guide to record-keeping to ensure compliance with the laws and regulations involved, but outlined below are a few of the most important things for dental assistants to remember when keeping records.

Why Is Record-Keeping so Important for a Dental Administrative Assistant to Get Right?

Dental records refer to the legal documentation of any and all information involved in a dental practice’s transactions and serve as a reference to guide dental practitioners in their treatment of clients and general operation of the office. These records contain all client communications, clinical notes, diagnostic information, insurance information, client history, and more. All of this information is essential for dentists to ensure good care and comprehensive treatment, as records provide information on the progress of a client, their history and past visits, and the general state of their oral health. Accurate and detailed record-keeping also ensures that a dental practice is safe in the event of a malpractice suit, and can play a role in informing healthcare statistics or assisting forensic dentistry processing. These records are also necessary to obtain payment from insurance companies and provide evidence of treatment. Overall, records are essential for maintaining both the health and safety of the client and the practice, and a dental administrative assistant should take care to ensure that they are accurate and up to date.

Keeping track of client visits and information is essential to good record-keeping

Keeping track of client visits and information is essential to good record-keeping

What Should Dental Records Contain?

Dental records contain a lot of information. Administrative assistants should reference official guidelines for a complete list, but there are some basic components necessary for all record-keeping practices. Records should contain the client’s information, including facts such as their age, birth date, contact information, and more. Records should also contain the client’s medical, dental, family, and drug histories, as well as allergies, copies of test results, recommendations, home care instructions, fees, and referrals. Records should also contain a complete log of client appointments and progress notes, follow-up attempts, and any nature of communications with the client. Records must accurately detail complete information on client prescriptions and instructions given. During dental administrative assistant courses, you will learn how to effectively keep track of this information in order to best assist a dental practitioner.

What to Avoid When Keeping Dental Records

What mistakes should students in career college programs watch out for? When keeping dental records, it’s important to remember that they’re entirely confidential, so it’s illegal to share or openly discuss any information provided in these records. Additionally, if an error is made or encountered within the records, it’s important to not completely erase the incorrect information. If using printed records, draw a line through the incorrect aspects in order to ensure that the redacted information is still legible in order to leave an audit trail and avoid suspicion of fraudulence. If using electronic records, it’s still important to never completely erase information and rather indicate which information is incorrect. 

Following these guidelines will ensure that the records you keep as a dental administrative assistant are accurate, keeping both dental practices and clients safe and informed.

Are you interested in becoming a dental administrative assistant?