What makes for great clinical notes?

It is a surprising fact that many offices do not document as thoroughly as they could. This is a major roadblock in the dental billing process that keeps offices from collecting 100% of what they are rightfully owed. How would you rate your office’s current clinical documentation? It may not be up to par, but you aren’t sure how to improve it. If you are unable to use it to support or appeal claims, we will break it down so you can get those clinical notes to rockstar status.

An easy acronym for clinical notes that dentists learn in dental school is SOAP, which stands for Subjective / Objective / Assessment / Plan. The goal of a SOAP note is to ensure all of the crucial information needed to support the claim for the procedures performed — and an appeal when necessary — is documented.

SUBJECTIVE — the patient’s chief complaint as communicated by the patient, history of present illness, location and severity

OBJECTIVE — vital signs, examination findings

ASSESSMENT — diagnosis, reasoning/evidence behind diagnosis if applicable

PLAN — how the provider will treat the patient’s concern

Why are clinical notes so important?

The short of it? If it isn’t documented, it didn’t happen. The patient’s clinical record is a legal record of the patient’s dental health in your practice, and it is becoming increasingly necessary to get claims paid. Some insurance carriers are no longer accepting independently written appeals, they will only accept the clinical notes from that date of service. 

With insurance constantly changing their guidelines for payment and coming up with new reasons to deny claims, the more clinical information you can include on a claim, the better! Any of the following additional supportive clinical documentation only increases the chances of a claim getting paid the first time:

• Current periodontal charting
• Current pre-operative x-rays
  • Bitewings within in the last 12 months
  • PA x-ray within the last 2 months
  • Panoramic x-ray within the last 5 years
• Pre-operative and post-operative intra-oral photos
• Pre-operative and post-operative x-rays for endodontic treatment, crown seat, and extractions

The dental billing experts at eAssist Dental Solutions know that there is no such thing as information overload when it comes to a dental claim. If you need assistance getting your claims paid and collecting 100% of what you are owed from the insurance companies, we are here to help.