While every patient’s record, and the notes it contains, must be specific to the patient undergoing examination and treatment, much of what is written in the chart can be seen as common to almost every patient. That can make it challenging to make what’s noted in the record seem unique to a particular patient. This reality of dentistry can make the concept of using templates, drop down boxes, etc., especially appealing because, after all, there are only so many ways of saying the same thing.
Frequently using template entries or copying entries from one patient’s records and pasting them into another’s can put a practice at risk, especially in the event of an audit. That’s because these shortcuts can make it easy to overlook blank fields in the record or cause the person writing the note to forget to customize notes. These types of oversights can raise red flags with auditors and prompt them to cast a wider net before closing the audit.
Practices that opt to follow a template approach in making notes in patients’ records should consider making notes that specify tooth-by-tooth status and treatment as well as procedure-by-procedure details. A good rule of thumb is that entries that are customized to the patient are always preferred to the frequent use of the same basic language in multiple records. While custom reporting may take more time, it also provides more protection in the event that a patient files some type of complaint against you or if you are selected for a random audit.
Some healthcare institutions and practices have begun to use “smart phrases” to help dentists report simple and commonly performed procedures such as dental exams and radiographs. If your practice decides to develop and use smart phrases, make sure that individualized data always accompanies the phrase. It’s also a good idea to have the phrases reviewed by an attorney, your professional liability carrier, or a compliance officer to review the phrases and ensure that they’re accurate.
A few sample smart phrases include:
- I was present in the operatory (during or when) this service was rendered and reviewed the patient’s health history, condition, treatment plan, and supervised the above services provided and documented.
- I was present in the operatory during or when (detail the service that was rendered) and (note findings and or the treatment plan as appropriate).
Another approach to making notes in the dental record uses the acronym SOAP, which calls for the person making the entry to consider the Subjective, Objective, Assessment and Plan. This system can also minimize the risk of failing to include important details in the record.
SOAP calls for:
- Subjective: detailing the patient’s chief concern and related specifics such as how long the patient has been experiencing symptoms, when and where any pain might occur, etc.
- This would also include updating the medical/dental health history information for existing patients and collecting complete information for new patients.
- Objective: This part of the entry deals with the patient’s current health status such as blood pressure readings, exam findings, radiographic findings and other diagnostic information, such as pocket depths, etc.
- Assessment: This is your diagnosis of the patient’s condition, based on the subjective and objective information. There may be several diagnoses to consider.
- Plan: The unique treatment plan recommended for the patient.
While SOAP is an effective tool for all patients, it can be especially effective when dealing with emergency appointments: gathering the information in this format is an easy way to collect everything needed in order to provide a customized note in the patient’s chart.
General Suggestions for Customizing Notes in the Dental Record:
- Document the conditions you encounter when you start treating a tooth.
- This information will be especially valuable if the patient returns with multiple complaints during the course of treatment.
- Make sure your entry lists both the findings at diagnosis and the findings at treatment.
- Consider including photos when treating patients. Pre- and post-operative images can support your diagnosis and treatment in the event that a patient claims they’ve experienced an injury as a result of the treatment provided.
- Include details about materials used during each procedure.
- Specify brand name, lot number and conditions whenever possible.