Adams School of Dentistry: Chart Closure Policy

Introduction

Purpose and Scope

The UNC Adams School of Dentistry (“ASOD”) must ensure that clinical personnel timely document patient encounters. Timely documentation and closing of encounters is critical for both effective billing practice and essential communication with other members of the current and future care team.

Background

Completion of records also influences a variety of financial and quality functions within the 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.

Policy

Minimum Standard

The minimum standard is that all providers, including Students, Adjunct, Faculty, Graduate Residents, and Graduate Teaching Assistants, must complete 90% of charts within eight (8) calendar days.

Reporting

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

Sanctions

1. In a fiscal year (July 1 - June 30), the first failure to meet the minimum standard will result in a verbal warning. 

2. In a fiscal year, the second (2nd) failure to meet the minimum standard will result in suspension of clinic privileges for a minimum of two (2) days, with best practice recommending two (2) days of advanced notice, to provide adequate time for patient schedules to be modified.

   • If chart closure is not 100% complete at the end of those 2 days, the clinical suspension will be extended until chart closure is 100% met.

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.

5. Any exceptions to this policy and the above sanctions must be approved by the Chair and Dean in writing and will only be granted for exceptional circumstances, such as major illness directly limiting chart completion.

Contact Information