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ARE YOUR CHART NOTES ADEQUATE?

 

1. Reason for visit:
a. Initial Exam
b. Emergency visit
c. Referral from another Doctor
d. Patient referral
e. Second Opinion
f. Consultation
g. Walk-in

2. Thorough review of health and dental history:
a. Discuss all “Yes” answers, make appropriate
notes,, and affix necessary warning stickers to
chart (inside chart).
b. Proactively ask, regardless of a “No” answer on
the Health history from, if the patient is allergic
to any medication or if he/she has been told he/
she has been told he/she needs to take antibiotics
before dental treatment.
c. Review the Health history and document the
Dental history of a new patient.

3. Patient’s chief complaint in his/her own words:
a. “The last tooth on the bottom right throbs all
night long and keeps me awake.”
b. “When I drink something cold it hurts on the
upper right.”
c. “I don’t like the color of my teeth”.
d. “Everything’s fine. I’m just here for a check-
up”.
e. “The tooth that doctor just did feel great”.

4. Symptoms (symptomatic or asymptomic)
a. How long
b. Location
c. Chronic or acute
d. Taking medication-what, when, how much, and
is it working?
e. Keeping patient awake at night
f. Interfering with eating or drinking
g. Throbbing (constant/intermittent)
h. Aching (sharp or dull)
i. Sensitive to heat, cold or air
j. Other

5. Clinician’s visual findings:
a. Location
b. No visual symptoms
c. Appears normal
d. Swollen
e. Broken lingual cusp
f. Inflames
g. Abscessed
h. Red and puffy
i. Cracked filling
j. Bleeds upon probing
k. Other

6. Diagnostic records:
a. Date of last x-rays/models/photos
b. Brought ______ from Dr. _____
c. At doctor’s request:
1. Took pa of # ______
2. Took panorex
3. Took maxillary occlusal
4. Took bitewings of _____
5. Took impression

7. Doctor’s examination:
a. Charted existing restorations and missing teeth
b. Completed full mouth periodontal probing and
examination
c. Soft and hard tissue examination
d. Charted necessary restorative treatment
e. Occlusion
f. Oral Cancer screening
g. TMJ

8. Doctor’s diagnosis:
a. No active caries
b. New caries # ____________________
Surface(s):____________________
c. Recurrent caries # ________________
Surface(s):____________________
d. Acute apical abscess #9
e. Periodontal abscess #30
f. Type II, III, IV, or V periodontal disease
(or AAP’s new dx. System)
g. Full bony impaction # 1, 16, asymptomatic, but
some cystic development around #16

9. Doctor’s Treatment recommendations: (Example
entries)
a. RCT #9 ASAP-good prognosis if treated
promptly
b. Porcelain Crown #9
c. Referral to periodontist Dr. ____________,
regarding periodontal abscess #30 and Type III
periodontal disease. Stressed to patient the need
to see the specialist Dr. ____________ within
the next week or risk losing tooth #30. Gave
patient the option that we call for her/him for an
appointment or they can call, patient chose to
call specialist.
d. Optional treatment of #30 if patient refuses to
see specialist; emergency periodontal scaling of
#30 with irrigation using antibiotic medications
ad prescription for oral antibiotics. Prognosis
poor including possible loss of tooth #30
without immediate treatment and subsequent
comprehensive periodontal treatment. “I
understand” stated the patient today.
e. Referral to oral surgeon, Dr.
________________, for assessment of #1 and
possible cyst involving #16.

10. Discussions with patient and his/her choice of
treatment; (Example of conversations):
a. Patient accepts RCT and crown recommendation
for tooth #9 and is scheduled for Monday June
6th at 8:00 am. FA is completed and patient will
pay in full at time of treatment to receive his
courtesy of 5%.
b. Discussed periodontal disease at length.
Patient was surprised/upset with diagnosis of
periodontal condition, stating the following: “No
one ever told me that before.” “I was getting
my teeth cleaned every 6 months”. Patient “will
think about it” and will “let you know after we
complete her/his treatment for #9”.
c. Discussed periodontal abscess of #30. Patient
accepted optional treatment to be done today.
She/He understands the poor prognosis but is
not willing to consider comprehensive treatment
at this time.
d. Patient not concerned about wisdom teeth
because “they are not giving her/him any
trouble at this time”. Dr shared with patient the
importance of having the cyst checked by the
oral surgeon, patient still refuses. Patient did
agree to have us recheck with another panorex in
6 months.

11. Treatment rendered:
a. Details regarding administration of local
anesthesia and other medicaments – exactly
what, when and how much.
b. Correctly document which procedure was done.
c. Document how the patient responded to
treatment, the prognosis and any other
recommendations or discussions with the
patient.

12. Items given to patient:
a. Prescription (in detail)
b. Special instructions to the patient
c. Post-op instructions
d. Informed consent
e. Signed refusal of treatment
f. Referral slips to other specialists
g. Other educational literature (e.g., brochures
relating to periodontal disease, endo, impacted
wisdom teeth, etc.)
h. Appointment card
i. Financial arrangement agreement

Why go to all this trouble?

Although this may seem like a lot of
documentation, thorough chart notes are the
cornerstone to providing quality dental care and
protecting your dental practice in the process.

Dental records are admissible in a court of law
because they are felt to be an accurate depiction
of what actually happened. Jurors tend to place
greater credibility on the written record rather than
the testimony of the doctor or the patient.

In essence, if it is NOT written down, it did
not happen, was not said and was not
performed.

By: Roz Fulmer

 

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