Effective January 1, 2016, Delta Dental of Alaska changed its policy to no longer accept written narratives in place of complete chart notes.
Chart notes serve as the legal document that should record all diagnostic information, clinical notes, justification for treatment, treatment performed and patient related communications. They should include:
- Medical and dental history
- Progress and treatment notes
- Conversations about the treatment needed
- Any instructions for home care and consent to treatment
Complete and accurate records should be legible and contain enough information to allow another provider who has no prior knowledge of the patient to fully understand the patient's dental experience with your office. In practices where there is more than one dentist, the identity of the dentist rendering the treatment should be clearly noted in the chart notes.
It is not necessary to send the entire chart notes, only the requested information that is pertinent to the treatment review. If the procedure code is on the 100 percent review list, you may send the requested information with the initial submission of the claim. To view this list, you may access your Dentist Handbook. |