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If It’s Not Documented, It Didn’t Happen
By Michelle Repash, Integrity Dental Billing & Consulting LLC
When most dentists think about clinical documentation, they think of it as a routine end-of-day task—a box to check after a busy schedule of patients. But in reality, your clinical notes are far more than a record of what happened that day. They are the foundation of your claims, your compliance, and your protection.
As someone who’s spent years on the front lines of dental billing and compliance, I can tell you: when documentation falls short, everything else crumbles. Your administrative team, your billing company, even your claims process—none of it can stand without solid, factual notes to back it up.
Because here’s the hard truth: if it’s not in the notes, it didn’t happen.
The Disconnect Between Policy and Proof
One of the most common mistakes I see is when the reason for a procedure—especially for replacements or major restorative work—is documented as “insurance allows replacement every five years.”
That’s not a clinical reason. That’s an insurance policy.
Insurance doesn’t pay based on their own benefit timelines—they pay based on clinical necessity, and that justification has to come from the treating provider. The note must answer the question: why was this treatment required for this patient, on this date?
When that story isn’t told clearly, the claim has nowhere to stand.
What a Proper Clinical Note Should Include
A solid clinical note should do more than check boxes—it should tell the story of that visit. Each entry is a snapshot of patient care, and it should include:
- The reason for treatment: What condition or concern made this procedure necessary?
- The diagnostic tools used: Radiographs, intraoral photos, periodontal charting—and what those findings revealed.
- Interpretation: What did you, the clinician, determine from those findings?
- Details of the procedure: What was performed, by whom, and with what materials or anesthetics.
- Start and stop times, and if applicable, a “time-out” verification for patient and procedure confirmation.
- Patient communication and consent: What was discussed, what was agreed upon, and any relevant patient feedback or concerns.
Each of these elements matters not only for clinical continuity but also for claim integrity and legal protection.
Keep Opinions Out—Facts Only
A rule I teach every team I work with: Keep your thoughts and opinions out of your notes.
Clinical notes are not the place for emotion, frustration, or speculation. They’re for facts only.
If you wouldn’t want to read it aloud in front of a malpractice attorney—or a state board—five years from now, it doesn’t belong there. Because if that day ever comes, that clinical note from the date of service becomes your only point of reference. You won’t remember the patient, the case, or the exact conversation—but the note will speak for you.
Write as if your professional reputation depends on it—because it does.
The False Claims Connection
Let’s turn the spotlight to the administrative and billing teams for a moment. When you write narratives or remarks in Box 35 on a claim form, your words matter—legally.
If you include statements that aren’t supported by what’s in the provider’s clinical notes, you could unintentionally be violating the False Claims Act.
For example:
If you write “tooth fractured to gumline” or “decay undermined existing restoration” but the dentist never documented those findings, you’ve now made a false statement on a claim, even if your intention was simply to clarify the reason for treatment.
That’s not just a compliance risk—it’s a legal one.
Documentation Is Your Defense—and Your Payment
At Integrity Dental Billing, we have a saying that guides everything we do:
“Your documentation is your defense—and your payment.”
Because both are true.
If it’s not written, it didn’t happen.
If it’s written wrong, it won’t get paid.
And if it’s not consistent across your claim, your notes, and your attachments, you’re creating unnecessary risk that can cost your practice time, money, and peace of mind.
The good news? Most of this risk is preventable. It just takes consistency, communication, and commitment.
Building a Culture of Documentation
Proper documentation shouldn’t feel like a burden—it should feel like a safeguard. When your providers and administrative teams work together, everyone wins.
Take the extra two minutes to document thoroughly. Train your team to align what’s written in the chart with what’s written on the claim. Review your notes regularly.
Because clean claims, compliance, and protection all start in the same place: with what’s written in that chart.
Billing with integrity isn’t just a slogan. It’s a standard—and it begins with the words you write every day.
Author Bio
Michelle Repash is the Founder and CEO of Integrity Dental Billing & Consulting LLC, a national dental revenue cycle management firm committed to compliance, transparency, and “Billing with Integrity.” With over two decades in dentistry, Michelle is passionate about bridging the gap between clinical documentation and claim success, helping dental teams protect their revenue—and their reputation.
