By: Howard Farran, DDS, MBA, MAGD, Publisher, DentalTown Magazine

Our Patient Services Supervisor recently came back from a “Women of Faith” Seminar where she listened to a speaker by the name of Patsy Clairmont. Patsy spoke on the topic of, “Carrying an Attitude with You”, or as she so perfectly titled it, “Sportin’ a ‘Tude”. Patsy actually brought out a tangled mess of rubber bands which she demonstrated as her attitude, or ‘tude for short. She showed how we drag our negative attitudes with us and at opportune times throw it out wherever and whenever we choose.

When starting and growing a paperless office, a positive attitude is so important. So many offices have bought the digital equipment necessary to go paperless, but a staff with a “Tude” is keeping yesterday from becoming tomorrow. Now staff – come on! Show me an office that went from scheduling in a paper book to scheduling on the computer that now wants to go back. You never hear this. I know change is stressful but you must swallow the pill and get rid of every non-digital process. When it is finally over and you have crossed the chasm, you will never look back and be soooooooo glad you did it.

The most common negative “tude” I hear is the idea that a paperless environment will take MORE time than the world of charts. This is absolutely not so. How can having all of your necessary tools such as x-rays, treatment plans and clinical notes accessible on one computer screen possibly take more time? I can see my patients’ FMX, pano, digital images, previous clinical notes, medical history, insurance information, and previous prescriptions all with the click of a mouse. I can even do this from home when I get a call from an emergency patient!! Doctors find it much faster than digging through the chart for all of this information. Assistants no longer have to develop the x-rays, print out the digital photos, and hand write notes in the patients’ charts. Like marriage, child rearing and paying your taxes, a positive attitude is critical to success.

A timesaving tool, which we use in our office for entering clinical notes in the computer, is called the SOAP format. This format has helped to streamline entering clinical notes. If you are not using this charting format, I highly recommend you start doing so. This will improve the communication between staff members. The format is as follows:

SOAP

S: SUBJECTIVE:
This section is for any information the patient tells the doctor or assistant prior to the start of the procedure. This would include information such as the MHU – Medical History Update, symptoms the patient is having, duration of discomfort, and so on.

O: OBJECTIVE:
This section is for any information the assistant or dentist sees before the start of the procedure. These types of things would include the results of any tests performed, such as cold or percussion, as well as any information seen on the radiographs.

A: ASSESSMENT:
This section is used to state the differential diagnosis and tentative treatment plan prior to the start of the procedure. This may be what was previously scheduled for the day’s appointment or it may be an emergency appointment with a narrative of the potential outcomes of the treatment to be performed. An example of this would be if the patient’s radiograph showed deep caries. The assessment would include notes on the planned excavation of the caries, what restoration would be placed, and what would be done if there were a carious exposure.

P: PROCEDURE:
This section includes what was actually done for the patient, such as the progress notes for the day’s appointment.

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RX: Any OTC (over the counter) or prescribed medicine written exactly as instructed. If there are none, don’t include.

NOTE: Any extra information that would be helpful or we forgot to put in the above sections. If there are none, don’t include.

NEXT VISIT: Include what needs to be scheduled and the recommended date (time frame), i.e. within one week. (Dr. initials).

LAB: What lab the crown/bridge/or prosthetics were sent to.

SHADE: The shade you or the patient picked for the restoration.

INS. EXP: You must write a reason why the crown/bridge or prosthetic was done. If existing crown/bridge or prosthetic is present, how old is that restoration?

Build-up Explanation: Build-up for increased retention.

These notes used for the SOAP format can be set up as templates in your practice management software or entered on each patient as needed. Your staff will appreciate the consistency of the clinical notes. They can easily find the next appointment and insurance explanations. Our office staff will print out the clinical notes and either attach to the paper claim or send electronically as an attachment depending on the insurance company. It’s all about letting go of the negative “tude” and moving forward to the paperless all digital environment. No one is claiming the transition will be all peaches and cream. There will be problems initially, but they are only speed bumps on the expressway to faster, easier, low-cost, efficient dentistry. Invest in the proper training for your staff for charting and digital x-ray. Once you have the tools and properly trained staff in place, your office will flow 100% better and everyone will be benefiting from the new “Tude”.