We have learned a lot of information about legal expectations when it comes to patient documentation. Therefore, it is important not only for the practice but also for the patient for dental professionals to record accurate, well-detailed notes about the patient visit. This allows for everyone in the practice to understand exactly what is going on with the patient without any ambiguity. This ensures that the patient is recieving individualized care by whomever the clinician is that day. We use a chart audit form to make sure that all documents are filled out and signed to its entirety. This helps us understand what mistakes we made and how we can do better as dental hygienists in the future.
As we get closer to the end of dental hygiene school, we have learned how to make detailed, concise notes. This has been a skill that we have been developing since the first semester and that is because it is important. Making detailed notes allows for the patient to get the care that they need and protects the clinician legally.