by Janet R. Hagerman, RDH, BS
As a dental hygiene coach and a temporary hygienist, I review many charts from different offices. They range from informative and interesting to grubby, disheveled, and totally illegible. Whether you are communicating with other health professionals, on your patient's behalf, or defending yourself in the unhappy event of litigation, clear and complete documentation is essential.
Here are 10 tips for ensuring optimal documentation:1.Information easily accessible — If your pages are bound at the top (not on the side like a book), be sure the information can be read without having to turn the chart upside down.2.Legible — Amazingly, only 36 percent of American dental offices are computerized. The majority of charts are handwritten. If your handwriting is not legible, make it legible or print. If your progress notes cannot be understood by other health professionals, how will they read in a court of law? All documentation must be legible.3.X-rays — I am always amazed at the charts I encounter with unlabeled, incomplete (obviously lost) radiographs. Our patients (and their insurance carriers) have paid for this visual documentation of our diagnosis. We have a responsibility to store that information securely. All X-rays must be secure in their holders (no loose films floating about) and labeled with the patient's name and date. They should be in a style of envelope that is placed in the chart in a way that they cannot fall out.4.Organized sections — Keep all of the insurance papers together in one section, all of the progress notes together, all of the lab slips together, all of the X-rays together, etc. An ideal organization includes color-coded pages for these sections. You will save a tremendous amount of time by not having to wade through mounds of unrelated papers to find specific information. 5.Tooth chart — It is not enough to document treatment on the treatment notes alone. It is annoying and frustrating when we have to hunt through pages of paper to learn if, when, how, and where a particular tooth was treated. Treatment notes give us the details of a procedure. The tooth chart reveals this information quickly and concisely in outline form. Include a sheet with a diagram of all teeth. Existing restorations should be indicated in blue pencil and work that needs to be done in red pencil. Several dental software systems will perform this function beautifully. Finally, of course, you must actually perform the exam and enter the diagnosis.6.Perio chart — According to the ADA, more than 75 percent of American adults have some form of periodontal disease — the major cause of adult tooth loss in the United States. Research is now showing a correlation between periodontal disease and heart disease. It is quite conceivable that, in the very near future, heart physicians will require a perio clearance from a patient's dentist before they perform heart surgery. Can you afford not to have a periodontal charting of every patient in your practice? All new patients should have complete six-point probing performed and documented at their comprehensive exam, and the chart should be updated annually.7.Treatment plan — I've seen treatment plans squeezed into the margins of progress notes, written on tiny index cards, and scattered throughout the chart. No wonder it becomes hard to enroll our patients in treatment. We can't find it! From a practice's point of view, as a business, this is probably the single most important piece of paper in the chart. A treatment plan should be on its own separate, official page (not a card or a scrap of paper). It must be complete and prioritized in order of urgency. Create a system for indicating when treatment has been completed. Create a simple treatment plan system and stick to it. One quick glance at this plan will allow each staff member (including temporary employees) to consistently assist in enrolling patient compliance to treatment. 8.Treatment/progress notes — This page should include procedures, types and brands of materials used, anesthesia details, and level of difficulty. Also include patient information such as compliance, cooperation, and comfort level. We cannot write too much. It is always better to overdocument than not give enough information. This is where we tend to get carried away with our scribbles. Remember, it's useless if we cannot read it. 9.Personal sheet — Use this sheet exclusively to maintain a personal history on each patient. When is the wedding? Was the new baby a boy or a girl? Did the patient get the promotion? Patients will be flattered that you took a moment to ask about their personal lives. This is vital to build and maintain rapport with our patients. It sends the message that we feel there is a person attached to that mouth. It can also become a great income-builder. Do you think tooth whitening might be of interest to the patient who is getting married or competing for a promotion? Keeping track of this information on separate sheet of paper helps everyone in the office to relate to each patient easily on a personal level.10.AADD — Now that you have the perfect chart, keep it in the perfect filing system. AADD is the best I have found; I see it in more dental offices every day. Advantages are reduced filing time by 50-80 percent, eliminated misfiling, and automatic chart audit. The letters AADD don't represent anything. The AADD system represents efficiency at its best. For more information about the system, visit the Web site at www.aads-filing.com.
This is the information age. Computers, intraoral cameras, digital radiography, and computerized probing will now make your illegible handwriting irrelevant and excellent documentation a breeze. All of the 10 tips above for ideal charting can easily and efficiently be documented electronically. The results are crisp, clear, and organized. Even with electronic documentation, we still need to perform the diagnostic procedures carefully and input the information correctly.
Regardless of the system you use, document information thoroughly in a secure, legible, and organized manner.
Janet R. Hagerman, RDH, BS, is a coach with Fortune Management. She can be reached at (888) 347-4785 or [email protected].