By Dr. Deborah Marynak
I’ve seen many well intended friends in dentistry come under scrutiny by attorneys and dental boards because of their lack of proper documentation. In their defense, I felt that in many instances, the education I received in record keeping was lacking. I recall asking many instructors questions regarding the soaping technique of documentation and never really understanding what it all meant. I only really learned how to properly document a chart after pursuing continuing education following dental school.
After I sold my dental practice I worked in several different venues. One of the universal problems I saw was the improper documentation of dental charts. The procedure was always there, but a whole lot of information was consistently missing. This made it difficult to review past treatment, diagnostic information and treatment plans. Often the treatment plan was done with red and blue pencil on dental charts that seemed a size only slightly larger than a postage stamp.
The Subjective section of the record:
This is the patient’s area; Blood pressure and heart rate are placed here. Everything the patient tells us is recorded in this area, including their chief complaints, changes in medications, medical treatments, questions and concerns regarding past and/or present dental treatment. The individual taking this information needs to understand what is being relayed to them and may even need to place information in quotes just as the patient expresses the information.
The Objective section of the record:
This is the provider’s area: An observation and professional description of the chief complaint in question is entered here. A review of the medical history and most importantly, a review of the medications are also recorded here. If this is an appointment involving treatment (vs. a limited oral evaluation), this is where a description of the tooth or teeth being treated is recorded.
The Assessment section of the record:
This is the diagnostic area: A diagnosis is made here based on the chief complaint, answers to questions regarding the chief complaint and the observation and professional description of the problem presented. If this is a simple restorative appointment, the reason why this procedure is being done is recorded here. There are five reasons why a tooth is diagnosed for a restoration:
1. decay 2. fracture 3. defective margins 4. inadequate restoration 5. patient request.
P: A complete explanation of the plan for the treatment in question
A: An explanation of all alternatives to the planned treatment
R: An explanation of all risks involved in the treatment
Q: A complete explanation and answering of all questions
The Procedure section of the record:
This is the description of the procedure: The type and amount of anesthetic, any medication/ prescription that was dispensed, all materials used (I like to document brand names in case of a rare allergic reaction), if it was adjusted, finished and polished and anything else that took place during that appointment.
During a treatment plan presentation, a competent Dental Health Professional should be in the consultation room with the doctor, documenting all of what is being discussed during the presentation. Once the doctor is finished presenting treatment options and answering questions, the financial obligation is presented and signed by the patient. This signature doesn’t bind the patient to treatment, it simply indicates that the treatment and fees have been present to the satisfaction of the patient and their questions and concerns have been addressed.
I can recall training the staff in a large private practice where I was hired as an associate dentist. I cannot express enough how many times, when patients claimed they’d never been told about a particular issue, we could simply read the documentation written during their treatment plan presentation and how it immediately defused a situation. Further, the patient who insists a prior authorization be established, allows the Team Member responsible for communicating with insurance companies to take your “objective” documentation and get the pre-auth sent without any delay.
Enough cannot be said about documentation, because we all know that if isn’t written down, it didn’t happen. Some of the most stressful, damaging situations have been created because communication, circumstances, behavior were not documented by the Dentist and members of his/her Dental Team. I’m also a huge proponent of documenting all cancellations and no shows. If you work the phones in a very fast paced office, keep a tablet on your desk to write down abbreviated conversations to document when things slow down. And remember…it’s not your interpretation of the conversation, but exactly what was said or what happened.
“A good rule of thumb is to assume that everything matters”
– Richard Thaler
Dr. Deborah Marynak is the owner of DentalStaffing.org, a dentist with over 30 years experience, and is committed to helping Dental Professionals find the right fit for both employees and employers. She also works with Dental Offices to help them streamline their clinical systems and teach Dental Teams how to effectively document to avoid risk.