Dental Recordkeeping Best Practices
September 2026
The American Dental Association (ADA) identifies the dental record as a legal document that should clearlysupport the care provided and the clinical decisions made.In addition to ADA recommendations, AHCCCS requires providers to maintain documentation that supports medical necessity, informed consent, treatment planning, and services rendered.
Key Documentation Reminders
- To help support efficient review of prior authorization requests and maintain complete patient records, please ensure:
- A diagnosis is documented for each tooth requiring treatment.
- Chart notes clearly identify the tooth or teeth being treated.
- Clinical findings support the requested treatment.
- Radiographs, photographs, and other supporting records are maintained when applicable.
- Narratives include the treating provider's name, signature, and date.
- Original chart entries remain intact. If corrections are needed, add a dated addendum rather than altering or deleting the original note.
Informed Consent and Treatment Planning
Dental records should demonstrate that informed consent discussions occurred with the member, parent/guardian, Health Care Decision Maker (HCDM), or Designated Representative (DR), including:
- Diagnosis and clinical findings
- Proposed treatment
- Alternative treatment options
- Risks and benefits of treatment
- Risks and benefits of alternative treatment options
- Risks and benefits of no treatment
Providers should also ensure:
- Written consent for examinations and preventive services is completed at the initial examination and updated at each six-month follow-up visit.
- Separate written consent is obtained for irreversible or invasive procedures, such as fillings, pulpotomies, crowns, and extractions.
- Treatment plans are reviewed, signed, and dated by both the provider and the member, parent/guardian, HCDM, or DR, as applicable.
- Signed consent forms and treatment plans are maintained within the patient record, and copies are provided to the member or representative.
Complete documentation helps support accurate benefit determinations, reduces requests for additional information, and helps ensure timely review of services. We appreciate your partnership and ongoing commitment to maintaining high-quality records for the members we serve together.
Additional Resource: