Once you have decided to go chartless, there are many decisions that need to be made. The following are some points you may want to consider when it comes to what you want to keep in the existing patient’s original hard copy, and what you want to input or scan into the computer. Remember, a lot of space is used when scanning in paperwork that may never be looked at again, and if you really need to look at it you can always pull the hard chart. There are also items that are just easier, in the long run, to input into the proper place instead of scanning the information into the patient’s chart.
First, do you input all of the existing patients’ information, or put the information into the computer as the patients return to the practice? By only inputting the information into the computer of the patients that are being actively seen in your practice, not only do you save time, you save money and hard drive space. You may also be surprised at the amount of patient retention you have. The hard chart can always be retained in the practice for future input.
When it comes to periodontal charting, one of the questions you should ask yourself is, what do we really need? Do you only want the original baseline probings that were taken when the patient first entered your practice? Do you want the last probings that were done on the hard copy of the periodontal chart? Do you want both? By putting in the last full mouth probings only, you will need to pull the chart in order to compare the patient's baseline, unless the probings have not changed since their first visit. You really need to consider putting in at least the last probings or the original probings from when the patient entered the practice, so you will have them readily available to compare to the newest probings. Existing fillings done by other dental offices should also be entered, and any treatment you have done in the patient’s mouth should be accurate and up to date also.
What x-rays will you want to scan in? At the least, you will want the last full mouth series and the last set of individual bite wing x-rays. Again, this is to enable you to compare old x-rays with current x-rays. If you are lucky enough that your bitewing x-rays were mounted in a progressive mount, then go ahead and scan in the entire mount. If you need to look at any x-rays further back, you can always pull the chart.
Will you use templates to create your clinical notes? Do you want to create your own templates so the hygienist is recording all of the information that you want noted in the chart? Where do you want specific notes to go? The entire staff needs to write any notes in the same area. This way everybody knows exactly where to go if they have any questions.
When putting in treatment plans that come out of the hygiene department, are you going to scan a written treatment plan in? Are you going to have a place where you can enter why the tooth needs the treatment written down? Doing this enables the hygienist to support the treatment plan and talk to the patient about what is going on with the specific tooth.
Do you want to scan all the health histories in or do you want to update everybody’s health history? If you decide to update every patient's health history and input it into the computer directly or scan it in, then you need to realize that every time your patients need to update their health history according to office policy, you will have to do the majority of the practice every time.
When deciding to go chartless, you do not need to reinvent the wheel. When it comes to the information you are going to input and where it is going to go in the clinical side of the chart, it is best to set it up just like the paper chart you have been using for years.
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