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Importance of diligent notetaking is off the charts
Importance of diligent notetaking is off the charts
Dental professionals are united by the series of words that we all, as health care providers, enter into a chart. It does not matter if we are a specialist or general dentist. We all need to write, dictate, or enter words into a chart that then becomes a legal document. It does not matter the way the way the information is written into the chart.But what we do or do not record can have consequences for or against us at a later date.
In fact, some of the most common questions that come before the Board are about documentation.
All documentation within the chart must be legible. If handwritten, no white our or blacked-out areas are permitted. If something needs to be amended, a line must be drawn through the error and initialed, before further writing can continue. If using electronic documentation, do not go back and change or delete items at a later date. It will show the documentation date out of sequence.
In both handwritten and electronic charts, it is imperative to have the dentist initial or identify the notes at every dated new entry. This prevents anyone else in the office from entering notes in the patient’s chart without the knowledge of the treating doctor.
Personal and derogatory comments about the patient or their family have no place in the treatment notes. If you feel that some form of destructive note about the character of the
patient is needed, place it in an area other than the treatment documentation. This legal document may someday come before a group of attorneys or the Dental Board. Personal and derogatory comments that were written in a volatile moment may end up harming you and your position.
Your documentation in a patient’s chart needs to create a medical story about the patient during the procedure. All notes should be clear enough that if another dentist reads through them he or she will have no trouble knowing what treatment was rendered and why. Further, they will know what the next step of the treatment plan would be.
Many dentists ask what should be written in
these notes. The following should be included in your documentation:
- Existing Conditions
- Perio Conditions
- Anesthesia, both type and amount
- Radiographs taken
- Medication prescribed
- Over-the-counter supplements or medications advised
- Treatment rendered
- Post-operatic instructions
- Verbal consent
- A patient’s signed consent form
- The next visit
- The next procedure to be completed
Although this might not be everything you include in your documentation, it does provide a solid framework of what needs to be recorded.
The dental office environment can be quite chaotic, bombarding us with distractions. Despite this, good record keeping is imperative for legal protection. The best time to enter records in charts is immediately after the procedure is done rather than waiting until the end of the day. This prevents important details from being overlooked or forgotten.
For your own protection, document completely and in a timely manner.
This will protect you and your patients.
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