Doctors question emphasis on perio charting
Dianne Watterson, RDH, responds to reader's question about doctor's opposition to perio charting.
Diligence with periodontal charting can be accomplished by saving time elsewhere
By Dianne Watterson, RDH, BS, MBA
I attended one of your seminars a couple of months ago, and since then I started a new job with two young doctors. The previous hygienist only charted probe depths occasionally, and there were no periodontal diagnoses anywhere in past notes for any of the patients. Another shortcoming is that there are no FMX radiographs for any of the patients, only BWs. So I am also trying to get patients caught up on radiographs. Most of the patients in this practice are older, so there are a lot of periodontal disease problems.
My problem is that even though I have an hour with each patient, sometimes I run 10 minutes or more behind. Yesterday, before leaving, the doctors expressed their concern about my running late and asked if all the charting was really necessary. I said that each patient needs to have a periodontal diagnosis, which is only possible by performing a periodontal charting. Since many patients do not have any recent charting, it is impossible to show the full extent of their attachment loss. How else can I support a diagnosis of moderate to severe periodontitis, especially with only horizontal BWs that don't even show the crestal bone?
I want to do what the doctors want, and I need to keep my job in this jobless market. But I also want to protect my license and make sure that I have everything documented. Any suggestions would be greatly appreciated.
From your post, it sounds like you are trying to be more comprehensive than the previous hygienist. The doctors probably have no idea how not having updated periodontal evaluations raises their liability risk. Of the top 10 reasons dentists are sued, failure to diagnose periodontal problems is No. 5 on the list. You'd think they would be glad that you are "busting your buns" for the good of their patients.
I'm not making excuses for the previous hygienist, but in many situations hygienists do not perform regular periodontal chartings because they don't have any help to get it done. This is especially true in offices where the hygienist only gets 40-45 minutes with the adult patient. It will take from 10-15 minutes for a solo hygienist to perform a full-mouth, six-point periodontal charting and recording if it has to be done solo. However, with an assistant doing the recording, the hygienist can usually get the probing/recording finished in about five minutes or less. There are also some wonderful software programs that assist the hygienist with probing/recording, such as Dentrix VoicePro speech recognition tool that allows for hands-free charting.
There are lots of things that can cause hygienists to run behind schedule, including waiting for a doctor exam or being disorganized. I urge you to try to pinpoint what is causing you to run behind and then develop a solution. It's not easy for any clinician to change speeds, but take a look at your protocol. Is there a process that you can streamline? One great time-saver for me was using a tray system. I had 10 plastic bracket trays that I would preload with all my disposables each morning. By doing this, I didn't have to continually open drawers all through the day to reset my operatory. Saving even a couple of minutes on each patient throughout the day adds up.
Another great time-saving tip I recommend is to implement an "interrupted hygiene exam" system. What this means is that you do not wait until you are finished to summon the doctor. Seat your patient and perform any preliminary items, including radiographs, medical history update, tour of the mouth, and any necessary chartings. If the patient has a lot of soft debris, polish first. Then summon the doctor. He or she can come anytime during the next 20-30 minutes.
When the doctor steps in the doorway, you would say to your patient, "I'm going to stop long enough for Dr. Smith to examine your teeth. Then we'll finish." The compromise is that the doctor may not get to examine a totally debris-free mouth, but the interrupted exam helps keep you on time. If you wait until you are completely finished to summon the doctor, you are asking to be kept waiting. Remember, the goal of the exam is not to check your work. The goal is to identify any restorative or soft-tissue pathology in the patient's mouth.
I also recommend that you resist trying to conquer the periodontal charting neglect issue in this office quickly, but rather over time. What I mean is this: If everyone needs periodontal charting, then choose some to do on this trip, and make notes to do others on their next visit. If you see about nine patients per day, make a goal to perio chart four to five patients per day. Over the course of the next year, you will have brought most people up to speed.
The doctors may also be concerned about fielding complaints from patients who are kept waiting. Some doctors are very prompt and pride themselves on seeing patients right on time. So if you are running late consistently, they've noticed and it concerns them.
In answer to the question posed by the doctors as to the necessity of "all that charting" I'd probably say, "I want to give your patients the very best care I can and having updated periodontal evaluations is an important part of that. Many-if not most-of the patients I've seen haven't been charted in a very long time, so it's a lot of work for me to try to get them up to speed. I'm sure you are aware that not having updated periodontal evaluations is a serious liability risk, and it's my job to inform you of any periodontal problems."
Once the doctors see that you are just trying to be thorough and conscientious, they will come to value your dedication to doing your job well. After all, it is part of the hygienist's responsibility to identify periodontal problems and bring that information to the dentist's attention.
Of course, having help with chartings can move things along much better than solo charting, and if you don't have help, you should ask for it.
It really makes me proud to find a hygienist that is aware of the importance of updated periodontal charting. So good of you, Shelby, RDH! Keep doing your best, but do try to stay on time as much as possible. And don't be shy about asking for help if you're not getting it.
All the best,
DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is an award-winning speaker, author, and consultant. She has published hundreds of articles, numerous textbook chapters, an instructional video on instrument sharpening, and two books. For information about upcoming speaking engagements or products, visit her website at www.wattersonspeaks.com. Dianne may be contacted at (336)472-3515 or by email firstname.lastname@example.org.