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The communication of any patient concerns to an ADA CERP and/or CODA accredited educational provider shall be documented in the patient report form and in the patient record, as appropriate. A signed ADA CERP and/or CODA CPD expiration report shall be submitted to the patient at the endpoint of each CERP or CPD.

Each summary of the total care plan shall clearly document the complete plan, its purpose and/or stage-wise progress on the basis of clinical data. It should be documented on concise, structured form, and should include specific information—specifically, the estimated timeliness of health care services needed to implement the planned plan, for example, precise timeline of upcoming appointments, if not already established by the clinician. The CPR form should be a completely revised version of the assessment and treatment schedule, also called the plan of care.

Be sure you are getting the right entry for treatment, care, or health-related information by carefully reviewing the most recent patient visit summary (see Appendix B). The care provider shall ensure that all information entered in and transferred from the chart to each module is accurate.

The care provider shall document all significant patient communication in contact notes, as well as diagnostic and treatment services in the treatment history. Radiographs, photographs, consultations, and correspondence relating to patient care shall be retained in the patient record.

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