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Protect and Build Your Practice by Carolyn Friedman

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Since orthodontic treatment is a long and involved process, documentation is a necessary part of what you do every day. Good documentation not only protects the practice legally, but can help build a good reputation and be a practicebuilder. From the first time a patient is seen until he or she is dismissed, every aspect of his or her treatment needs to be documented. It doesn’t matter if you are paperless or not, whatever system you use, do not overlook the importance of accuracy.

I have noticed over the years that we don’t remember every little detail, but parents forget aspects of the starting state of their child’s treatment. I recommend recording everything from the first phone call. Every communication you have with patients and their parents should be documented. It might sound over-the-top but it is a necessary part of every practice.

The First Phone Call
    You should document the following information:
  • Who initially called to schedule the appointment?
  • Is the patient seeing a general dentist regularly?
  • Why does the patient believe he or she needs to see an orthodontist?


I know you are probably questioning why these things are important. It’s important to know who called for the appointment because the parent who called to schedule is the one who received the information about what your office will do at that appointment. But another parent might be the one who brings the patient to the appointment. It is very valuable to the doctor and treatment coordinator to be aware that the person at the appointment might not be fully informed and additional explanation could be necessary.

Knowing if the patient is seeing a general dentist is also important. If he or she is not seeing a general dentist, it slows down the process of starting orthodontic treatment, as he or she might need a cleaning and complete check-up before initiating treatment.

Why the parent or patient believes orthodontic treatment is needed is definitely the most valuable information to the doctor and treatment coordinator. This information let’s you know what their concerns are. You must first address what brought them into the office before you address other orthodontic issues. If you don’t address concerns at the initial appointment, chances are you will lose them as a patient.

I would also want to know if the patient was previously scheduled and did not show up for his or her initial appointment, especially if it happened several times. This is very important to know before starting orthodontic treatment on a patient, as there are many appointments required over several years and commitment is necessary.

Initial Visit
Photos are a great way to document the condition of the teeth and the bite. By the time you remove the appliances, the patient has forgotten how it all started. It is wonderful to be able to pull out photos and show that a tooth already had a chip on the incisal edge before treatment was initiated. The length of time that a patient wears appliances has a tendency to mask the little things that become large things when he or she has nothing on the teeth. One parent even thought that having braces had turned her child’s teeth dark. But in fact, the discoloration and the teeth being dark were very apparent on the original photos.

Treatment Plan Documentation
If a patient has several treatment options available, make sure it is documented that these options were addressed. For instance, if a patient would have a greater improvement and final result with orthognathic surgery but he or she chose not to have a combination orthodontic and orthognathic approach, note that it was discussed or recommended. There are many cases of patients or parents saying “no” to considering surgery, but then when faced with the treatment limitations upon completion, do not seem to remember the discussion and the choices that they made. Maybe a patient is missing a lateral and decides that he or she doesn’t want to have an implant or bridge but wants the space closed, it is imperative that this is documented.

During Treatment
When you’re seeing a patient for an emergency, try to determine why he or she is having an emergency and document the details. If you find a piece of popcorn or bubble gum stuck on the loose bracket or broken wire, state this in the patient’s file. Many times parents will say at the front desk or on the phone that he or she didn’t do anything wrong, things just came loose. Though there are some cases with incidental breakage, the truth is, usually it is more of a direct action and direct result issue. Many times the patient will say something different than what the parent said when he or she called; we need to document these conversations and the actual situation.

When the parent or patient calls with an emergency, make sure the person answering the phone asks the right questions. The next step is to relay that information to the clinical assistants. When the patient shows up for his or her emergency appointment, it makes the office look incompetent if the assistants appear clueless as to what kind of problem the patient is having. When the assistants are familiar with the problem, the patient feels like your office is on top of things. Ask the parent to snap a photo of the patient’s problem before coming in and send it via e-mail or phone. This can help clarify if an emergency appointment needs to be made. In other instances, a photo could possibly eliminate an unnecessary emergency appointment or allow you to schedule at a more convenient time for the practice.

When a patient needs an emergency appointment and you offer several options, none of which will work for him or her, make notes that you offered several times and dates but the patient was unable to take any of them, so you scheduled further out. Eventually, a mom or dad will come in and tell the doctor that they wish they could have been seen sooner. At this time, you can look at the notes and see that your office did try to accommodate them sooner. The reply to the parent would be, “Yes, we are sorry that none of the earlier times we offered would work for you, but we will certainly take care of the problem today.”

Another important point to document is if a patient is a no-show or cancels an appointment. This really helps to determine how you need to handle rescheduling. Many times there are very good reasons why someone cannot make it to an appointment, but sometimes he or she is just trying to get another more convenient time or doesn’t feel it is important to show up at the regular scheduled appointment. I was in an office and they were complaining that Johnny was always coming for a late afternoon emergency appointment and then the office would always do his regular appointment at the same time. This patient had the office right where he wanted. We sometimes create our own problems.

The message the office was sending was “if you don’t want to show up for your regular morning appointment, call and say something is wrong and be seen in the afternoon, after school, and not only will we take care of your problems but we will also take care of your regular appointment.” Stop and think about who just won! Not the practice and staff, or your schedule, and certainly not the other patients who came in on time for their regular appointments. The problem is compounded if a patient can cancel or no-show today and get back on the schedule within a day or two.

Being able to look back and see what has happened throughout the patient’s treatment period with a patient’s scheduled visits is so important when trying to complete treatment within the estimated time or to explain why the treatment was not complete as originally scheduled. It is vital that patients understand from the start of treatment that keeping scheduled appointments is where they play a big part in completing their treatment on schedule.

If we approach things properly then we will be able to show respect to our patients’ time and schedule. Remember, documentation is very important to an orthodontic practice since the treatment is over the period of several years.

Good documentation will not only protect your practice legally, but can keep your office on schedule, build patient confidence in your office and staff, and therefore increase referrals… because patients will refer their friends to offices that are on top of things.
Author’s Bio
Carolyn Friedman continues to work in the same progressive orthodontic practice that she has worked for 39 years. Beginning as an orthodontic assistant, and having worked in every area of the orthodontic office, she is currently the office manager, clinical coordinator and treatment coordinator. She is the founder of OrthoAssist, a business focused on orthodontic consulting and training of orthodontic staff members. She is also the author of the OrthoAssist Library, interactive programs consisting of training programs for all areas of the practice. Carolyn is a continuing education provider for the Florida Board of Dentistry, conducting educational programs for hygienists on orthodontic appliances, their application and care. Learn more at www.orthoassist.com.
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October 2025
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