When it comes to dental documentation, are you doing all you can in your dental practice? Most of the time, the answer I hear is “no.” Dentists and hygienists were taught in school how to construct legal chart notes and obtain clear x-rays, but what about dental assistants? Too few dental assistant training programs teach this and let’s also consider that dental documentation, although similar, can vary from doctor to doctor. Therefore, if the dental assistant was trained in one practice, when they move to another practice they are lost because dental documentation is generally doctor specific. We’ve got you covered. No matter your clinical role in the dental practice, keep reading for some dental documentation best practices.
Why is dental documentation important?
Dental documentation in the form of clinical notes is the foundation of dental treatment and the dental billing process. In order to send a clean dental claim, the patient’s clinical notes need to be able to support the data on the dental claim.
Comprehensive dental clinical notes should consist of:
- the patient’s medical history
- x-rays
- oral evaluations
- treatment proposed
- treatment rendered
Also, always include previous information that was gathered either by your practice or another practice where the patient had their records transferred. It tells you the story of the patient, where they were, and where they are now. This information is vital for the dental billing specialist to support the appeal process if the patient’s dental claim is denied for any reason.
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Dental documentation should include the medical history
Far too often, when I ask practices how often they update a patient’s medical history, they say, “once a year” or “every three years”. The unfortunate truth is that patients do not correlate their oral health to their overall health. So when we ask about their medical history so infrequently, they forget or don’t believe it has anything to do with what we are doing, so they don’t need to bring it up.
Once, while working on a patient upon numbing him, his heart began to race. He let my doctor know and of course, the doctor told him that was typical of the Epinephrine, to just give it a few deep breaths and it would go away. This has happened many times in my career and it always goes away.
The patient then says; “Is this going to affect my pacemaker?”
With a dropped jaw, the doctor looked at the assistant to which the assistant pointed to the digital chart. The patient had signed and updated their health history moments before but never said a word about a pacemaker!
I can’t stress enough that patients do not look at us as medical providers so, therefore, do not see the need to discuss their medical conditions with us. I like to ask open-ended questions such as:
- When was the last time you were seen in the hospital emergency room?
- When was the last time your doctor changed your medication?
- When was the last time you were seen in a hospital setting for an outpatient procedure?
You would be completely surprised to find that patients will say all kinds of things that you can use to obtain the best information and lay the groundwork for treatment. Often, they will list an additional medication they left off the medical history form.
Dental documentation can help patients
Another aspect to think about is that many patients see a dentist more often than they see their physician. We have the opportunity to be their best advocate when it comes to getting them medical attention sooner than later. But first, we have to educate them that we are indeed oral healthcare providers and that making the oral-systemic connection is our mission.
Many offices not only take blood pressure but do a finger stick for blood sugar and check pulse oxygen levels as well. By collecting & documenting these findings, we can discover potential problems the patient didn’t even know they had. Not to mention, avoid a medical emergency in the dental practice.
Dental documentation & compliance
Dental documentation doesn’t stop there. An intact clinical note is detailed and critical for protecting the patient and the practice, should something be called into question. Your state dental board, or any legal representative, can gain access to these records very easily. They can be evidence in a court of law. Now that you know you are actually creating potential evidence, it makes sense why dental documentation is so important.
The problem is, most of the time we don’t know it’s evidence until several months later. By then, whatever dental documentation you have recorded is a done deal.
Pro tip: Never, ever go in after the day of service to construct or edit a clinical note. Dental clinical notes should be done the day of treatment, contain detailed information about the procedure, conversations, medical histories and if the assistant is making the note, then read and signed by the doctor — the same day.
All providers (dental assistants are not providers) should be reading and signing clinical notes. Do not make the mistake of allowing yourself to skip this step. You may be blindsided when this gets called into question and you didn’t know what it contained. Never assume the notes are acceptable, especially when there are trusted resources to help you.
Dental documentation & dental claim narratives
Many of the dental softwares have an “auto note” feature. This allows you to create a somewhat fill-in-the-blank clinical note system. You can customize this template to fit your own individual needs. While these are handy, these templates need to be updated and edited annually.
The doctor or provider needs to be the one to construct the clinical note and allow the dental assistant to make changes as necessary. If your software doesn’t have an auto note feature, or if you are still a paper chart office, then construct your own written template so your assistant can refer back to it when constructing the dental clinical notes. Again, make sure you, as the provider are diligently reading, adding, or editing, all clinical notes daily.
Need a dental clinical note template? SOAP note and ParQ note templates are popular.
S.O.A.P stands for:
Subjective — Statement about relevant patient behavior or status
Objective — Measurable, quantifiable, and observable data
Assessment — Interpret the meaning of S and O
Plan — Anticipated frequency and duration, course of treatment for the next session, recommendations, and any changes
P.A.R.Q. stands for:
Procedure — Describe the recommended procedures/treatment plan to patient
Alternatives — Describe any alternatives to the recommended treatment (including refusal of treatment). Also explain the possible outcome if treatment is rendered.
Risk — Explain any risks that may be involved with proceeding with treatment, as well as the risks of declining treatment.
Questions — Allow the patient or any advocate for them to ask questions and answer all questions thoroughly.
How you construct your clinical notes is up to you. However, with insurances requiring the dental clinical notes to be submitted with the dental claim as a dental narrative, make sure your notes contain the details listed in these two templates. Your dental billing specialist with thank you.
Get help with dental claim narratives >>>
Dental documentation extends beyond the patient
Dental documentation stems far beyond the patient. Yes, we should be making notes when patients cancel, no-show or have conversations with the front office administrative team, but that is not the extent of it. There are several OSHA, Infection Control and HIPAA requirements that need to be documented as well.
As a matter of fact, annual team training needs to be documented and kept with our OSHA and HIPAA manuals as proof. Also things like required spore test reports, daily sterilization logs, required protocols, such as a laundry policy, training policy, infection waste policy, HIPAA security and privacy measures, to name a few, are all a must when it comes to documentation. We not only have to train our teams, but we must prove that we did it, and have all protocols written out to refer back to for team members, or to train new team members! All of this documentation is just as important to keeping a practice running smoothly, and out of hot water if something should happen. Please don’t underestimate how crucial these things are to your practice.
Dental Documentation with Confidence
In summary, documentation is far more important than ever for your dental practices now. With several team members responsible for creating and maintaining any notes in our practice, we must be doing our due diligence to make sure these records are accurate and up to date.
But there is so much to know, and remembering every single detail is not always realistic. Imagine having a resource that could help you with:
- Guidelines for Dental Claim Narratives and Clinical Documentation
- Electronic Narratives
- Patient Records — Proper Documentation and Reporting
- Guidelines by Category of Service
- Consequences of Improper Documentation
This resource exists. CLICK HERE to get your copy of Dental Documentation with Confidence 2023 from Dr. Charles Blair and team, before they are gone!
About the guest author:
Tija Hunter is a dental assistant that loves to help other dental assistants thrive! She consults in offices that need OSHA/Infection and HIPAA training and coaching. With over half of her DA workforce trained OTJ, she feels it’s important that she get them the proper training. DA’s spend more time with the patient than any other team member, so let’s educate them to be their best!
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