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Clinical Notes vs. Narratives

New for 2018 is a renewed emphasis by Delta Dental National Processing Policy on the importance of clinical notes vs. narratives when submitting explanations or justifications on your pre-determinations or claims. Delta Dental National Policy now states that “Narratives as documentation are not considered legal entities nor are they contemporaneous in nature. The patient record/clinical notes are considered a legal document and are contemporaneous. The only acceptable legal written documentation for utilization review are the contemporaneous treatment notes.” There is a general rule in a court of law that states that “if it is not in the clinical notes, it did not happen”. Narratives have proven to be unreliable sources of information for consultants and, therefore, the new emphasis on providing documentation of important information through your legal clinical notes which include radiographs, periodontal chartings, anesthesia records, etc. is very important.