If I were to be hired in your practice today, would I know what happened with your patients the last time they were in? We were all taught in college to make sure to utilize good documentation when it comes to our patient’s records. What exactly is good documentation? What do we really need?
Unfortunately, we may not know exactly what we should be documenting until we end up in court. Hopefully, we have done our job of having good documentation in order to avoid actual litigation. However, most dental malpractice suits today involve the misdiagnosis and failure to properly treat periodontal conditions. Dental hygienists may be held liable if breakdown is not detected or if “supervised neglect” occurs.
There is a multitude of ways to document treatment records. The most important issue is standardization and continuity between providers in the office. Also, patient records must be thorough, containing precise information relating to existing oral conditions, treatment recommended, treatment administered, self-care recommendations and follow up care.
One method of record keeping that encompasses the above factors is the SOAP system. SOAP (Subjective, Objective, Assessment, Plan) is designed to center only on the problems and concerns of the patient and eliminates unnecessary information making records specific and explicit. The abbreviations are used to indicate conditions and treatment; every clinician in a practice should utilize the same system with the same abbreviations. This provides for a way to easily interpret the notes.
SOAP notes are common-sense approaches to record keeping. After S (subjective) and O (Objective) findings are noted, the patient’s condition is A (assessed) and a treatment P (Plan) is formulated. It is a logical sequence of events and can be utilized at every Interceptive Periodontal Therapy appointment.
The SOAP system is a valuable asset to the dental hygiene department. It standardizes treatment documentation. Therefore, different clinicians can easily interpret the notes and can readily convey treatment outcomes between one another. The SOAP system only records information pertinent to the needs of the patient. It follows a logical chain of thought from documentation to treatment. Thus, helping to make sure no important facts are inadvertently forgotten and keeping records complete.
Another method that may be used along with the SOAP method is to create a self-inking stamp and use it in addition to the SOAP method. The stamp may have on it the following routine procedures done by the hygienist.
- Px. = prophys
- PerioMaint. = Periodontal maintenance
- Hemo. = Hemorrhaging gen = generalized
- plq = plaque gen = generalized Lt. = light Mod. = Moderate
- rad = radiographs ________
- This is where the hygienist will write what x-rays were taken
- WNL = within normal limits
- OHI = oral hygiene instructions TB = toothbrush RT = rubber tip
- OH = oral hygiene
- Calc. = calculus gen = generalized subg = subgingival
supg = supragingival
- anes. = Anesthesia Init. = Operators initials________
The stamp allows the hygienist to circle the correct abbreviation that applies to the individual patient. This will help save time when it comes to record keeping.
Any additional notes will be made using the SOAP method. These abbreviations are just a few of the standard treatments performed by the hygienist that you may want to include on the stamp that the hygienist would use. Additional examples of abbreviations are included in McKenzie Management’s book, “Enhance Your Hygiene Department.”
Each practice should have a staff member assigned to the development of a record keeping protocol. The most important issue is standardization and continuity between providers in the office. Also, patient records must be thorough, precise information relating to existing oral conditions, treatment recommended, treatment administered, self-care recommendations and follow up care.
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