Paperwork. I don’t know anyone who likes doing it… including me. But when it comes to documenting patient care, it’s important. Having stated this, we really aren’t taught to do it well. In dental school we document to prove competency, which means we are writing for reasons beyond immediate care of a specific patient. After graduation, for the most part, I would say most of us write too little.
Here are a few ideas about documentation that I have found useful.
1. When I first meet a patient, I take notes with a blank sheet of paper, writing down what the patient says in the same way I would take notes during a lecture. Typing on a computer seems a little too impersonal so I don’t use it.
2. When taking an oral history of the patient, I don’t insert my opinion. If the patient seems mad, I don’t write that the patient seems mad. Instead I quote what he or she says. This moves documentation away from subjective or opinion statements and toward objective or observation statements.
3. When writing an entry in the record I have a simple outline in mind. Here is my basic order of notation.
b. Patient’s Name (if it isn’t located elsewhere on the page)
c. Procedure Title (what is today’s procedure?) The reason I like to do this is because later on when I am looking back on my notes it is easier to read through titles than it is having to read through entire entries.
d. Medical Status Statement and Vital Signs — in order to address the unstated question of whether or not the patient is healthy enough to have the planned dental procedure. Here are examples of entries I often make.
— “Reviewed health history and patient states no changes in health status.”
– “Patient states she is now taking [name of medication].
e. Consent Statement. I know it is routine for patients to have to sign long documents giving informed consent, however, I still like a simple statement in the record (which the patient does not have to sign, by the way) that says something like, “We reviewed the treatment plan for today and alternative options to the proposed procedure. She verbalizes understanding and wished to proceed.”
f. Next, I recount important steps of the procedure and want to write down everything I did that involves medications and materials used. Also if there were any problems, I want to clearly write this down as well. Plus I always try to inform the patient as to the outcome of the procedure, documenting this as well.
g. I state that post operative instructions (written and oral) and list all prescriptions have been given to the patient.
h. And now here is one of my biggest tips for this area of patient care. I make it a point to always make the last line the “Disposition” or “Next” line. This makes it easy for everyone else in your office to schedule patients without asking you what is planned next. In addition to simply stating what the next appointment will be about, I also state if there are other treatment steps planned further out. For example, if I placed a dental implant, then I will state when I plan to see the patient next for the post operative visit. Also, I want to state when I plan to do the next step for the dental implant and therefore make a statement as to when will it be ready to uncover or restore.
To summarize: The start of every entry should have the date and the patient’s name (this also protects against writing patient information in the wrong dental record). Followed by the title of the procedure. Then comes the body of the entry followed at the end by a disposition line. Making each entry conform to this basic outline enables others in my office to quickly see what was done on a particular day and what comes next without having to read through the entire entry. The middle section documents medications and materials as well as important steps I will likely forget should I fail to write them down.
So here are three things that help me determine what I need to write down with each written in the form of a question. You might consider writing these on a card and keeping it handy as you work to improve your methods.
1. What do I need to write down for medical/legal reasons?
2. What do I need to write down in order to not forget something that may become important later?
3. What do I need to write down that will help my team understand patient flow, i.e. how to schedule and how to bill?