Adams School of Dentistry: Timely Documentation Policy

Title

Adams School of Dentistry: Timely Documentation Policy

I. Introduction

A. Purpose

Timely documentation of patient encounters is critical to patient care, patient safety, provider communication, and effective billing practices. Completion of records also influences a variety of financial and quality functions within the Adams School of Dentistry (ASOD) and the UNC Health system. Best practice is to finalize patient notes same day. The electronic health record is the most efficient method of communication to other persons who also provide care to ASOD’s patients. Accordingly, documentation standards are necessary to set expectations for timely chart completion. The Chairs of clinical divisions are ultimately responsible for assuring that providers in their respective divisions adhere to ASOD policies. Uniform documentation standards are necessary for consistency and clarity.

B. Scope of Applicability

This Policy applies to all ASOD members who contribute information to patient charts regardless of whether the encounter occurs in the Student Dental Clinics, Graduate Dental Clinics, or Dental Faculty Practice.

II. Definitions

1. EHR: electronic health record system used by the ASOD.
2. Licensed provider: any individual employed or otherwise acting on behalf of the ASOD that is licensed to render or supervise patient care in the State of North Carolina. Licensed providers includes those who are duly licensed, as well as those with instructor's licenses, intern permits (e.g., residents), or other applicable permits that may be granted by the North Carolina State Board of Dental Examiners.
3. Percentage of progress notes finalized and signed: the number of completed billable encounters assigned to the provider divided by the total number of billable encounters assigned to the provider.
4. Student: any individual enrolled in the ASOD's educational programs that is not a licensed provider but is authorized to render patient care under the supervision of a licensed provider, such as DDS and Dental Hygiene candidates.

III. Policy

A. Minimum Standard

The minimum standard is that all providers must complete 90% of charts within eight (8) calendar days.

B. Reporting

A monthly notice will be sent to each Division chair or designee, reporting each provider’s performance, the number of open charts and associated delinquency.

C. Exceptions

Notes that could not be closed for reasons over which the provider has no control may be excluded from the calculation. Such reasons may include (but are not limited to):

1. Computer system failure or other technical error.
2. For supervising faculty, failure by a student or resident to complete underlying documentation in a timely manner.
3. For students and residents, failure by supervising faculty to complete documentation in a timely manner.

The burden of proof is on the provider to identify notes that should be excluded from the calculation. Providers should keep documentation to support their position.

IV. Enforcement

This Policy will be enforced through monitoring and sanctions. Any provider who fails to complete and sign 90% of their progress notes within the timeframe established within the "Minimum Standard" section are subject to sanctions. All sanctions must be applied in accordance with any applicable University or ASOD policies.

1. In a fiscal year (July 1 - June 30), the first failure to meet the minimum standard will result in a warning.
2. In a fiscal year, the second failure to meet the minimum standard will result in suspension of clinic privileges until the minimum standard is achieved.
3. In a fiscal year, the third failure to meet the minimum standard means that a provider is not eligible for any incentive for the quarter in which the provider failed to meet the minimum standard for the third time.A resident who has failed to meet the minimum for a third time will have their stipend suspended for three months.
4. No certificate for a resident in an advanced dental education program will be issued unless 100% of charts have been completed.

The responsible official(s) below are required to submit an annual report to the Dean's Office listing any provider who falls below this expectation and the sanction that was applied.

A.Students

The Chief Dental Officer or designee(s) will monitor student compliance with this requirement at least annually and prescribe sanctions for individuals - in consultation with Academic Affairs - as appropriate.

B. Residents

Graduate Program Directors or their designee(s) will monitor resident compliance with this requirement at least twice per year and prescribe sanctions for individuals - in consultation with the Associate Dean for Advanced Dental Education (ADE) - as appropriate.

C. Faculty

Supervisors (e.g., Department Chair) or their designee(s) will monitor compliance by faculty or other licensed providers employed by ASOD as part of their annual performance review and prescribe sanctions for individuals - in consultation with Human Resources - as appropriate.

V. Related Requirements

1. North Carolina Administrative Code, 21 NCAC 16T .0101 - Record Content
2. North Carolina General Statutes, Chapter 1, Article 51 (N.C.G.S. §§ 1-605 through 617) - North Carolina False Claims Act
3. Federal False Claims Act (31 U.S.C. §§ 3729 through 3733)

VI. Contact Information