Documentation in Supportive Periodontal Therapy

(This is a continuation in a series of blog posts about Supportive Periodontal Therapy (SPT) for dentists, dental hygienists and even interested patients – what it is and how to do it).

Failure to effectively document Supportive Periodontal Therapy is akin to failing to provide treatment in the first place because

 IT’S NOT JUST A CLEANING APPOINTMENT.

We are so conditioned to “providing care” that we sometimes forget that it is often more important to document progress and provide recommendations compared with the transient effects of a cleaning procedure. More to the point, if we operate under the assumption that when it comes to SPT we are not the primary therapists, our patients are, the focus of our activities will logically shift away from a procedure mentality and more toward a coaching mentality.

Effective documentation provides perspective to the care of a chronic condition. Seeing pocket depth change as well as changes in inflammation, both in specific sites and in general, enable us along with our patients to know what to do now and what we might expect in the future. Keeping good records, including documenting conversations about findings and plans with the patient, means that we help them better understand when treatment beyond the routine supportive appointment will become necessary in the future.

This isn’t the only reason documentation is valuable in SPT. Think of it from the patient’s perspective. When we and our teams record important information and continually take the time to communicate with patients, our relationships with them changes. The most cost effective marketing is treating our current patients with high levels of respect.

Failure to keep the patient informed is to assume yourself, by default, the responsibility for the success of all periodontal treatment. Also failure to document means that whatever you say has only the weight of your memory. Isn’t it interesting how often patients (including me when I am a patient) conveniently forget bad news and over-weigh positive remarks. When was the last time you heard, “But I thought you said I would never need treatment again…” I hope the answer is never, but I can’t say this myself. It’s not fun, however, when you have good documentation, such statements are not a big problem. All that is needed is to simply review the record with the patient once again. Quickly, they will understand that they have been informed before and none of the therapeutic principles have changed. (I will go into more detail on all of this when we look at active therapy in the next few months.)

Here are a few of my random tips on documentation

  1.  Create a general outline for you and your team. By having an outline and even a policy about written patient entries, everyone in the office will be able to quickly and easily both write and understand the entries of others. Some computer programs allow you to write a template. I think this is a good idea, only be careful not to fall into the trap of simply checking boxes for every patient. You need some evidence that your remarks are specific to the individual patient and that you took some time and thought about them. Remember, there will come times when you will need to refer back to your entries and they should be descriptive enough to be of help. In other words, your primary reason for writing good entries has to do with helping you quickly and smoothly come back into to the treatment of patients you have often not seen or thought about for months.
  2. Don’t forget to date your entry. I know this seems obvious, but in the heat of battle it is easy to overlook. Without a date, the information can lose all relevance. Some computer programs time-stamp the entry. If you are late by a day in making the entry don’t attempt to edit an old unfinished note. Instead on the new date first write the date the patient was seen and then write “Late entry” or “Missed entry.” This level of accuracy is important because it indicates that you are not altering entries after the fact.
  3. Begin with updating the patient’s medical status. Has anything changed medically since the last appointment? Blood pressure and pulse are required to be recorded in my state. This is a good and important idea in my opinion. Frankly, it takes more energy to complain about having to do this than it does simply doing it habitually. Also it is another piece of evidence that you value the health of your patients more than you do being able to do procedures on them.
  4. Dental status/chief complaint. Before diving into periodontal issues, has the patient had any dental problems or concerns since the last visit? It’s never wrong to simply quote the patient’s words into the record. Remember, every identified problem must have a statement as to what was done about it.
  5. Periodontal charting/comparison charting. As I stated above, without this, you are not performing SPT. Charting and comparing the charting with previously recorded ones is foundational to, and synonymous with, SPT. (And make sure the dates are clear.) Let me make one more fundamental point. Recording bleeding separate from pocket depth is a huge mistake. It is understanding and responding to the combined information of bleeding to probing with pocket depth changes that is at the core of what SPT truly is and how it works.
  6. Calculate and record the BI score (% sites bleeding). What is the point change since last time? Look for trends.
  7. Record the Advanced Sites. How many advanced sites are present and how has this changed since last visit?
  8. Consultations. At what point should hygienists consult with dentists immediately? In my opinion, all advanced sites as well as bleeding indices over threshold (as I have said, mine is set at 20%, yours might be set at 10%) warrant a consultation. This is because these findings may change the course of care to be provided today and possibly in the immediate future. However, what if the dentist is tied up and cannot come to see the patient immediately? The hygienist can always proceed with the treatment planned and hold up on any forms of advanced treatment the patient has not agreed to ahead of time. Obviously the sooner the dentist can enter the discussion, the better for all.
  9. Patient consultation/recommendations. What was discussed with the patient? This is often overlooked and seems less significant compared with step 8. I beg to differ. When patients are kept continually informed, even when (or especially when) there is bad or difficult news, it enables them to make intelligent decisions. Also when patients are informed of good and bad news as findings come up without first attempting to “soften” blows, it comes across as more honest and forthright. Of course we want everything we do to work for patients, but when it falls short, the best thing we can do is to state that the result has fallen short.
  10. Treatment performed. Be brief. If Arestin is used state locations. Also marking on the comparison periodontal chart where Arestin has been placed helps keep track when repeat applications have been provided on consecutive visits.
  11. Disposition or Next. This is always my final line. Of all the tips I have, this one is probably the best one. Always state what is to happen next – and by next, I not only mean next time, but all the steps that are clear to you at this time. In other words, the final entry is the current treatment plan as far as you know at this time. When other dentists call or the assistant wants to know how to set up for the next procedure, before coming to ask me this question, they know to check the last line of the last entry. P.S. I write “Next:”  and then go from there. Disposition is simply longer and means the very same thing to me.
  12. Share your entry with partnering dentists. As a periodontist, I have a choice between writing periodic formal letters to referring dentists or simply sending them every entry I write for myself so they can put it into their own records. I have chosen to do the latter. Of course, at the end of every entry I write my patient disposition statement, which may be telling the other dentist he or she needs to see the patient next and the reason for the visit. A few dentists I work with are learning the benefits of sending me their patient entries on mutual patients as well. One of the benefits of doing this is the fact that I can then remind the patient of treatment they need from the other dentist. It also enables me to reinforce to the patient the importance of following through with this care.

I think I’m close to wrapping this topic up and starting on the white paper. If you would like this SPT white paper, which as of this date has not been written, please let me know. I am keeping a list and once it is completed I will email it out. My hope is to complete this project and move to the next topic by the end of the month. Thanks to all of you who are making comments either in the LinkedIn discussions are right on my blog. Happy New Year.

 

4 Comments

  1. Yes I would like a copy. Thank you for your time.
    Janet Gillespie RDH

    Reply
    • Dr. Benjamin Young

      My pleasure. You’re on my list.

      Reply
  2. I am a general dentist with a High focus on perio control and stability, I’m definitely interested in this White Paper! Thank You.

    Lucynda

    Reply
    • Dr. Benjamin Young

      You’re on my list. Thanks.

      Reply

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