Are dental office staff (e.g., dental hygienist, dental assistant) permitted to write the treating dentist’s initials on the patient’s clinical notes and Medical History Form updates/recalls?

Office personnel are allowed to make entries to the chart, but cannot imply they are in fact being made by the dentist. Office personnel that enter the treating dentist’s initials shall also put his or her initials indicating that the entry was made by someone other than the treating dentist. Although there is a need to identify who performs the task, there is no specific requirement that the individual performing it must create the entry in the patient's record.

Answer is informational only and not intended as legal advice. Answer may contain excerpts from The ADA Practical Guide to Frequently Asked Legal Questions.