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Five Powerful Reasons to Document Rhonda R. Savage, DDS, CEO, Linda Miles and Associates

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Five Powerful Reasons to Document

by Rhonda R. Savage, DDS, CEO, Linda Miles and Associates

You must always remember that a dental record can be a shield if properly completed. Your assessments, findings, impressions, plan of care, treatments and prescriptions all warrant careful, timely, legitimate documentation. You cannot anticipate who or why you might have an issue with a particular patient. I was an “on-the-job” trained 17-year-old assistant, right out of high-school in Ketchikan, Alaska. My boss – a red-headed, hot-tempered, Irish doctor – taught me to “write a book” when it came to charting. One day, a man walked into our office who happened to be a cruise ship passenger. Teeth #24 and #25 were periodontally abscessed and extremely mobile. The only option was to extract the teeth. The patient said, “No, I think I’ll wait until I get down South to see a ‘real’ dentist!”

My boss’ face turned red and he replied, “See that pharmacy? Go buy some Ibuprofen!” And he stomped out of the room. A month later, I was back at college and received a phone call from my boss. He thanked me profusely for all my efforts with charting. I asked, “Why? What’s happened?” Turns out that patient went back on board the cruise ship and somewhere between Ketchikan and Seattle, he bludgeoned his traveling companion to death with a whiskey bottle!

His companion was the heiress to a big fortune. When the authorities caught up with him, he said, “I don’t know what I did. I must have blacked out… from the medicine the dentist gave me!” The findings were that she died in Canadian waters. The authorities were going to make my doctor go to Canada to testify, but because the charting was so complete, he didn’t have to go! You never know when or where a legal issue can come from: protect yourself! In addition to protection, effective charting can increase communication, case acceptance and improve your professional reputation. The following five reasons serve to reinforce proper and thorough documentation in your practice:

1. Proper charting will increase your ability to communicate
Problem: One of the greatest frustrations of front-office staff is when patients, after being treated, present themselves to the front desk with no chart or an incomplete chart entry. The front-desk staff is forced to make small talk. They feel incompetent at times and at other times, unprofessional when questions go back and forth, or they must run down the answers. Solution: Don’t touch the up button on the dental chair! The doctor needs to smoothly pass the baton to the assistant by saying: “Frank, everything went very well today. I’m going to leave you in Kathy’s very capable hands. She’ll finish your chart and answer any questions you might have. I look forward to seeing you next time!” All charts must be complete prior to walking the patient to the front desk. If there is a need to route the chart back to someone, do put a note on the chart, with name and date. The note stays on the outside of the chart.

Problem: In some offices, I’ve seen the next treatment plan written on a yellow sticky note and stuck in the chart. Sticky notes fall off. Without the patient’s name and date, there’s no way to reference it back to the needs of the patient. Ladies and gentlemen – sticky notes are not a legal document. Solution: Use the chart forms, diagnose thoroughly. Remember the five P’s: Prior Proper Planning Prevents Problems!

Problem: Your front-office team needs detailed descriptions charted at the time of diagnosis for two reasons. One is to have the proper descriptors for insurance submission; the other is to be able to logically talk with patients about their needs. Solution: Anytime you diagnose definitive dentistry, write a description: “Tooth #3 needs a crown and a build-up: Existing MODL amalgam, recurrent mesial decay, fractured DL cusp and biting/cold sensitivity.” If the patient calls to reschedule or postpone, your front office should pull the chart and communicate the need for this appointment.

2. Complete charting leads to higher levels of case acceptance:
Problem: Lack of attention to detail. Patients leave dental practices when they become annoyed with lack of attention to detail. In fact, research shows that 85 percent of patients leave due to what they perceive is a lack of customer service. Solution: Consider your charting to be a form complete customer service. When the patient makes subsequent phone calls with questions, your team will be better able to address the patient’s concerns.

Problem: Poor charting leads to higher team stress and tension. There are three basic needs of customers: friendliness, a reasonable wait time and a good atmosphere. It’s nearly impossible to have a good atmosphere or a reasonable wait time if the chart is not complete. Solution: Talk openly at team meetings about disgruntled patients. One significant issue is lack of communication. How can you better meet your patient’s needs?

Problem: Inadequate documentation: With a comprehensive examination, including periodontal charting, soft-tissue charting, oral cancer screening examination and recorded existing restorations, your front office can help you draw up written treatment plan estimates. The patient can sign the estimates; the patient receives a copy and one is retained for the chart. Lack of diagnosis and charting of periodontal disease is the number one reason for malpractice litigation. I’ve seen a wide range of practice diagnosis of periodontal disease, from “We don’t chart. We refer when it gets ‘bad enough’” to “We chart at every recall.” Solution: A complete periodontal charting is done on an annual basis, with spot probings recorded on a recall/maintenance visit.

3. Establish or improve your reputation in the dental community:
Your dental office cannot be 1,000 times better than other practices, but you can be better in 1,000 small ways. With complete treatment planning, attention to detail and thorough charting, you can communicate more effectively with the specialists in your area.

Problem: Many offices scratch out a note on a referral pad or dropping a quick e-mail, missing details crucial to the success of the case. Solution: Consider writing a well thought out letter of referral. You can do this quickly by asking your staff for their help.

Rough out a letter of referral that includes the patient’s concerns, your findings and your recommendations. Copy other specialists on all letters for completeness. Send copies to your patient. Ask your team to include the patient’s health history and insurance information. Call the specialists with any private concerns prior to the patient’s visit in their office. When the specialists see your attention to detail, with your letters and with your dental treatment, do not be surprised if they refer to you those patients seeking a general dentist!

If you are a specialty practice, be certain to send timely detailed correspondence to your general office. It is a great front-desk frustration when the patient presents, ready for implant restorative treatment, only to discover the patient is not yet ready. Proper charting and documentation is crucial for good communication between the general dentist and the specialist.

4. Great documentation prevents malpractice suits:
Problem: The patient chronically fails appointments. You dismiss the patient, but the failures have not been documented in the clinical record and all of a sudden you’re accused of patient abandonment. Now you have the unnecessary stress of contacting your malpractice insurance agent, hiring a malpractice attorney, gathering the records and defending yourself. Solution: All patient communication needs to be documented in the record. (See sidebar.)

To be frank, this is where “going chartless” is such a benefit and time saver. If you do not have to play the game of “chase the chart” you’ll be way ahead time-wise. All patient discussion needs to be documented. If you’re scheduling for anything, you must pull the chart. Otherwise, how do you know when and what to schedule?

5. Charting error prevention:
Problem: Inaccurate charting that doesn’t reflect the daily scheduled treatment. Solution: Do a triple check prior to anesthesia. The staff checks the clinical chart, the patient’s mouth and verifies with the patient the treatment he or she is to receive. The doctor mirrors the team’s efforts upon entering the treatment room.

This might seem redundant, but guess what? It is! When you or your family had your last surgery, how many of the hospital team asked these same questions? It’s important! In addition, complete your chart entry with the very easy-to-see entry, noting: NV (Next Visit): What is the patient returning for? How much time will you need? Make this easy for your front office; this will also facilitate your triple check. Problem solve where the error came into play. Was the NV noted correctly? Scheduled correctly? Did the patient reschedule and was the treatment not carried forward properly?

We need to have the ability to talk about what’s wrong in our practices in order to correct the problem. Oftentimes, the problem is a lack of team training and communication – not a problem with one particular person. We cannot expect that which we did not train for. Train your team how to make chart entries.

I like team members to make entries. It is timely and saves the doctor time. Train your team to write for you. Use a template, but also do not ever forget the narratives. The narratives give you strength in a court of law. Proper charting is your only defense. If it didn’t get written down, legally, it didn’t happen. Remember that the chart will be blown up to a full sized projector screen if you get taken to court.

Look at the entries carefully for spelling, proper English, grammar and professionalism. Train your team to write for you. Give them a script and ask them to “write a book.” The doctor’s responsibility is to review the chart on a daily basis. Everyone making an entry needs to initial the entry, including the front office staff. Any entry that needs correction gets a single line through the faulty area and the correction is written above and initialed. No blank lines exist in a chart. Ever.

If the entry is not complete or accurate, route the chart back to the staff person for correction. Then it comes back to the doctor for final review. If not correct, route it back again. Until team members know what to do and can do it themselves, the errors will continue.

State law varies. For a comprehensive understanding of legal charting requirements, contact your malpractice carrier. Consider a malpractice prevention course update; many insurance companies hold these courses complimentary for their member dentists. Remember, it’s never a question of whether or not you’ll be sued, it’s a question of when.
Author's Bio
Dr. Rhonda Savage began her career in dentistry as a dental assistant in 1976. After four years of chairside assisting, she took over front-office duties for the next two years. She loved working with patients and decided to become a dentist. Dr. Savage graduated with a BS in biology, cum laude, from Seattle University in 1985; she then attended the University of Washington School of Dentistry, graduating in 1989 with multiple honors. Dr. Savage went on active duty as a dental officer in the U.S. Navy during Desert Shield/Desert Storm and was awarded the Navy Achievement Medal, the National Defense Medal, and an Expert Pistol Medal. While in private practice for 16 years, Dr. Savage authored many peer-reviewed articles and lectured internationally. She is active in organized dentistry and has represented the State of Washington as President of the Washington State Dental Association. Dr. Rhonda Savage is the CEO for Linda L. Miles and Associates, known internationally for dental management and consulting services. Dr. Savage is a noted speaker who lectures on practice management, women’s health issues, periodontal disease, communication and marketing, and zoo dentistry. To speak with Dr. Savage about your practice concerns or to schedule her to speak at your dental society or study club, please call 877-343- 0909 or e-mail rsavage@harbornet.com.
 
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