by Carol Tekavec, CDA, RDH
While correct documentation of a patient’s dental appointment is essential, it is not the only reason for a visit. It is true that we must be concerned about accuracy and completeness, as well as the importance of the dental record as a legal document. Also, most issues with insurance carriers hinge on accurate records. (If you have ever received a letter from a third party carrier asking for a refund, you know what I’m referring to.) However, producing accurate and complete records, whether paper or digital, does not have to be an arduous task, and it most certainly is not the only point of the patient’s appointment.
The keys to accurate recordkeeping can be found in the acronym PDTCIN — Documentation of Presenting conditions and medical history, Diagnosis, Tooth-by-tooth treatment plan, Case treatment plan, Informed consent, and relevant progress Notes.
Basic requirements for PDTCIN are:
Medical and dental history (Presenting conditions)
Current thinking on a proper patient medical history says the following should be included:
- Comprehensive information collection, including systemic diseases, allergies, and medications.
- Name and phone number of patient’s medical doctor.
- Appropriate medical alert that makes medical concerns obvious (red sticker, red circle, highlighted area, etc.).
- Baseline blood pressure and pulse documentation section.
- Dentist review section with the dentist’s comments and signature (or personalized electronic code) in addition to the patient’s signature.
- Updated at least once a year, or more if there is a significant change in the patient’s health.
Patient’s “chief complaint,” or what brought him or her to the office. (Presenting conditions.) This is relevant, both for documentation of presenting conditions and subsequent treatment planning.
Initial data collection (Presenting conditions)
- Status of the teeth and other existing conditions
- Pathology present — should include surfaces decayed, fractures, cusp involvement, existing endos, bone support, and others
- Occlusal evaluation
- Soft tissue and cancer evaluation
- Periodontal conditions including probing depths, bleeding sites, furcations, mobility, and recession.
Diagnosis and treatment plan (Diagnosis and Tooth-by-tooth plan)
Based on initial data collection and the dentist’s diagnosis, a treatment plan needs to reflect what is planned for each tooth and how this will take place, appointment by appointment, for the entire case. (Case treatment plan)
Informed consent
According to legal advisors, consent should be obtained for “any procedure that is not commonly done or easily understood.” (Theoretically, this can be any procedure!) A dentist needs to decide what procedures should trigger documented consent. Consent is a process, not just a form. However, even though consent can simply be acknowledged in the patient’s progress notes, a detailed, treatment-specific, patient-signed-and-dated form focuses on the fact that a treatment has been explained and agreed to. A treatment-specific form should include treatment recommendations and the risks of these, alternative treatment recommendations and the risks of these, the consequences of doing nothing, the fact that questions have been answered, and a notation that fees have been discussed. (See a sample booklet of 31 informed consent forms at www.steppingstonestosuccess.com.)
Written treatment/fee estimate
A written fee estimate which has been explained to and signed off on by the patient is a great tool. This way everyone knows what is expected financially. A copy should be kept in the patient’s paper record or in the digitized file, and the patient should have a copy to take home.
Progress notes (relevant progress Notes)
Progress notes function as part of the “legal” aspect of a patient’s record. They are also essential for treatment continuity. They must be detailed. If written, they must be legible and contain no “white-outs” or erasures, and all entrees must be signed or initialed by the dentist. If digitized, they must be authenticated by a password, fingerprint or other scan, or key ID. Why must the dentist acknowledge progress note entries? Without his or her written acknowledgment that the notes are accurate, anyone in the office can enter anything in a patient’s record. Progress notes need to include:
- Anesthetics used, including type, amount, carpule expiration date, and result. Indicate “no anes” if none is required.
- Radiographs exposed and what they revealed, treatment accomplished, complications noted, medications given, prescriptions given, (even those over the phone), shades, materials, labs, follow-up instructions, and anything else pertinent to the patient’s care.
For example, “3/09/10, SRP right side. Home care. Local anes” is not detailed enough.
A better notation is: "3/09/10 SRP max and mand. right. Local anes, 1 carp for each mand and max. Lidocaine 2% 1:50,000, exp. 2/11. Adm. by CD Tekavec RDH. No N2O needed. Heavy tenacious calculus, esp. facial of max molars. Tissue edematous and bleeds easily. Home care inst. included floss, brush, period aide, and gave to patient. Advised pt to rinse gently with warm water and take home pain reliever if necessary. Called pt at 5pm to check on him. He reported being a little sore, but ok. CD Tekavec, signed by Dr. M. Smith."
Digitized progress notes may exist in some programs as “segments” or “macros,” whereby an operator may use a single keystroke to copy a sentence, paragraph, or more, into a patient’s digital record. If this is the case, it is very important that any “macro” used is relevant. For example, some digitized “macros” include one to two carpules of anesthetic for each restoration. This could result in a patient’s digitized record showing six carpules of anesthetic for restorations on tooth Nos. 2, 3, and 4, when only two carpules may have actually been used.
While documentation is important, it is not the only point to a patient’s visit! It is likely that the digitized format used by this physician’s office is thorough, however, my friend would have appreciated a little human interaction.
For those of us in dentistry, it is helpful to consider a patient’s chart, whether paper or computer, as ongoing documentation and an integral part of our relationships with patients. It is not necessary or even possible to complete all aspects of accurate charting and recording at the patient’s initial visit. During a new patient exam, a medical history, chief complaint assessment, and initial data collection may be possible. A second appointment may be scheduled for beginning treatment, but a complete treatment plan might not be possible until later. A written estimate and informed consent forms may be presented at the end of a new patient exam or at the beginning of the next appointment. And progress notes do just that, progress. A patient’s record is developed, not created in one fell swoop.
A Web-based digital chart can be purchased through various companies for a set-up fee of about $500 (depending on the forms the office wants, special forms may be more expensive) and a monthly fee of around $125. The patient’s information can be kept at the Web address, with some forms downloaded by patients in advance or by staff at the office. Digital files, such as radiographs, may or may not be possible to be merged with a Web-based chart. In addition, insurance claim generation, recall reports, scheduling, and other practice management functions must still be accomplished with in-office formats not related to that chart.
An in-office practice management system, including a fully electronic record, can cost between $15,000 and $30,000. This would probably include computers in all operatories, monitors, operating systems, digital radiographs, and all aspects of accounting, ordering, scheduling, insurance claim generation, and report generation. Training of clerical and clinical staff in a fully electronic office is another expense.
It is not often mentioned, but is a true fact of life that clinical staff is rarely as enthusiastic about computer-generated activities in the operatory as the clerical staff. Why is this? A clinical staff person, such as an assistant or hygienist, often has picked a hands-on profession due to a preference for patient care, not office responsibilities. Clerical staff is rarely as adept at patient care activities for the same reason. Therefore, when clinical staff, who are responsible for patient care and treatment, are tapped to take on some of the duties of clerical staff (written fee and treatment estimates, insurance claim generation, statement generation, scheduling, computerized progress notes, and more) in an operatory-based system, staff members may become discontented and patient care may suffer. This does not mean that computers are not in the future of all professions. They are here to stay. It means that a focus on staff strengths and the development of a comprehensive dental model still remain to be seen.
