Patient Record Audit: Suggestions for Buyers
By Megan Urban
– Randomly select patient records and review for complete documentation, full mouth diagnosis, necessary x-rays, and regular maintenance.
– Review the most recent three to five new patient records for charted existing and diagnosed “ideal” treatment, perio charting, appropriate x-rays, and confirm if the patients have their next scheduled appointments.
-Review the three most recent endodontic patient records to confirm if buildups and crowns were treatment planned and scheduled, or if treatment has already been completed.
-Review the three most recent prophy and SRP patient records to confirm the accuracy of treatment is captured in hygiene notes, proper documentation, and x-rays.
-Review the schedule for the upcoming weeks/months for all providers including hygiene. See how far out the hygiene scheduled is booked. In a strong hygiene program with a good recall and scheduling system in place, hygiene should be booked out five to six months.
-Review the schedule for the previous week to verify how many no-show or late-cancel appointments occurred. How were the no-show and late-cancel appointments documented? How are they tracked? Were the patients charged a fee?
-Run the Active Patient Count Report to confirm the number of active patients.
-Print the Detailed Treatment Plans Report (or Unscheduled Treatment Plans Report) and research several accounts to verify if treatment is truly needed, or if it was done and the treatment on the report is actually a second or third option. Is there sufficient dentistry left for you to do?
-Look at the Accounts Receivable Aging Report to determine if the amounts owing are from insurance or from the guarantor/responsible party. Are patients accustomed to paying their estimated portion at the time of service?
-Look at the Credit Balance Report (or Unassigned Credit Report). Credit balances can result from prepaid treatment, unposted treatment, incorrect insurance adjustments, or may be due to the patient or insurance company as refunds.
-Look at the Outstanding Claims Report for claims over thirty, sixty, and ninety days. Are the staff members responsible for the accounts receivable on top of outstanding claims? Look at the account notes for claims on the over ninety-day list to see why these claims haven’t been paid. Were they submitted with the correct codes, narratives, and necessary attachments?
-Look at the Month End/Day Sheet Reports for the past several months to see the production to collection ratio.