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Should the doctor sign their own chart notes?

Can someone plz tell me who is supposed to write the notes after a procedure, the doctor or assistant? At my first office the doctor wrote everything re: procedure & the assistant wrote only what she did (BP, temp,etc). At this current office the assistants write everything & he doesn’t even sign it. I was taught that the Dr is suppose to at least sign for legal reasons. Is there any supporting evidence if that’s the case? Thank you

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1 Answer

Every state has different rules and regulations, so this question would probably be best answered by your state’s Board of Dentistry for the most accurate answer. With that said, this is from the American Dental Association:
Who Makes Entries in the Record?
Attorneys and doctors debate who should make the entries in the dental record, but state law will determine this in most cases. Keep in mind that the dentist is ultimately responsible for the patient’s chart. Some entries may be delegated to office staff if allowed by state law. The administrative assistant can record telephone calls; prescription changes; and canceled, changed, and failed appointments. The dental assistant records the patient’s comments, concerns and disposition; vital signs; medical history notations; radiographs and other diagnostic tools taken and used; and instructions given to the patient, etc. Dentists add clinical impressions, treatments performed and any pertinent information. All entries should be initialed and/or signed by the team member writing the entry and the dentist.
If the dentist opts not to make his or her own entries, he/she should dictate what to write to the assistant. The dentist should review the contents of the entry as soon as possible for accuracy and then sign or initial it.
From Page 11 of: https://www.ada.org/~/media/ADA/Public%20Programs/Files/MPRG_Dental_Records.pdf?la=en

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