What should be included in the documentation when a red flag for pathology is detected during Direct Access care?

• A. Only the patient’s consent
• B. Observation notes without clinical data
• C. Documented red flags, clinical assessment findings, discussion with supervising dentist, and referral per policy
• D. A note that no action is needed

Answer: (C)

When a red flag for pathology is detected in Direct Access care, the emphasis must be on thorough, auditable documentation that shows why concern exists, what was found, and how it was handled. The record should explicitly note the red flags or concerning findings, the clinical assessment or differential diagnosis based on the exam and any tests, the discussion you had with a supervising dentist, and the referral action taken per policy. This creates a clear, traceable narrative that explains the reasoning behind the decision to involve another professional, ensures patient safety, and supports continuity of care and legal accountability. It signals to any other provider reviewing the chart exactly what prompted concern, what steps were recommended, and what the next actions are.

Documenting only consent leaves out the clinical basis for concern and doesn’t show the decision-making process. Observation notes without clinical data miss the essential information needed to justify the red flag. And stating that no action is needed ignores the seriousness of a red flag and can put the patient at risk and expose you to liability. Including the identified red flags, the clinical assessment findings, the discussion with the supervising dentist, and the referral plan per policy is the responsible approach in Direct Access practice.