DENTAL CLINICAL AUDIT CHECKLIST 2026: DOCUMENTATION & TREATMENT ACCURACY

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--- PATIENT IDENTIFICATION & CONSENT VERIFICATION ---
[ ] Date of Patient Verification
[ ] Patient Full Name
[ ] Patient Date of Birth
[ ] ID Verification Method (Driver's License, State ID, Passport, Other)
[ ] Required Consent Forms Verified (Informed Consent for Procedure, HIPAA Privacy Notice, Financial Policy Agreement, Medical History Consent)
[ ] Auditor Signature

--- CLINICAL DOCUMENTATION & PROGRESS NOTES ---
[ ] Date of Clinical Encounter
[ ] Note Format Used (SOAP Note, Narrative Note, Brief Procedure Note)
[ ] Summary of Clinical Findings
[ ] Documentation Components Present (Chief Complaint, Medical History Update, Diagnosis, Treatment Rendered, Anesthesia Administered, Post-Op Instructions Given)
[ ] Auditor Verification Signature
[ ] Scan of Signed Progress Note

--- DIAGNOSTIC IMAGING & RADIOGRAPH INTEGRITY ---
[ ] Radiograph Types Reviewed (Bitewing, Periapical, Panoramic, CBCT, Occlusal)
[ ] Image Quality Status (Diagnostic & Clear, Suboptimal - Motion Blur, Suboptimal - Artifact/Error, Incomplete/Missing)
[ ] Anatomic Findings Noted
[ ] Date of Imaging Capture
[ ] Upload Radiograph Sample for Audit
[ ] Auditor Verification Signature

--- TREATMENT PLAN ALIGNMENT & EXECUTION ---
[ ] Treatment Plan Status (Planned, In-Progress, Completed, Deferred)
[ ] Verified Clinical Milestones (Initial Exam Completed, Radiographs Obtained, Patient Consent Signed, Anesthesia/Sedation Risk Assessed, Cost Estimate Provided)
[ ] Discrepancy Notes
[ ] Clinical Deviation Details
[ ] Date of Treatment Execution
[ ] Auditor Verification

--- PERIODONTAL & CHARTING ACCURACY ---
[ ] Date of Periodontal Assessment
[ ] Periodontal Status Classification (Healthy, Gingivitis, Periodontitis - Stage I, Periodontitis - Stage II, Periodontitis - Stage III, Periodontitis - Stage IV)
[ ] Average Probing Depth (mm)
[ ] Observed Clinical Findings (Bleeding on Probing (BOP), Recession, Furcation Involvement, Mobility, Calculus Deposits)
[ ] Detailed Charting Notes
[ ] Clinician Verification Signature

--- PRESCRIPTION & MEDICATION MANAGEMENT ---
[ ] Medication Class Prescribed (Antibiotics, Analgesics (Pain Relief), Anti-inflammatories, Antiseptics/Mouthwashes, Anesthetics)
[ ] Drug Name & Dosage
[ ] Specific Instructions Provided to Patient
[ ] Date Prescription Issued
[ ] Allergy Alert Verified (Yes, verified with patient, No, update medical history)
[ ] Auditor Verification Signature

--- LABORATORY & ANCILLARY SERVICE TRACKING ---
[ ] Date Lab Order Sent
[ ] Type of Lab Service (Crown/Bridge, Denture/Partial, Clear Aligner, Implant Abutment, Other)
[ ] External Laboratory Name
[ ] Expected Delivery Date
[ ] Required Components Included (Impression/Scan, Bite Registration, Retraction Cord, Digital Photos)
[ ] Digital Scan or Lab Slip Upload
[ ] Clinical Lead Verification

--- POST-OPERATIVE INSTRUCTION & FOLLOW-UP DOCUMENTATION ---
[ ] Post-Op Instructions Provided (Verbal Instructions Given, Written Instruction Sheet Provided, Digital/Email Instructions Sent, Emergency Contact Info Provided)
[ ] Post-Operative Care Level (Routine (Simple Extraction/Filling), Complex (Surgical/Implant), Endodontic (Root Canal))
[ ] Follow-up Appointment Date
[ ] Specific Post-Op Notes/Alerts
[ ] Clinician Verification Signature

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