In college I was taught that writing more in a clinical note is better than not writing enough. I was also taught that anybody in the practice should be able to pick up a patient’s chart and know exactly what went on during their appointment. As a result, when I go into a practice and see “prophy, polish, probe, oral hygiene instruction and periodic exam” written in a patient’s record as the clinical note, I just want to cringe.
Many times it’s what is not written that matters the most. It may seem like you are just having idle conversation as you make the patient comfortable in the chair during your meet and seat. But if patient Tom mentioned that he is going to be retiring in a few weeks, months, or even a couple of years, this is pertinent to the patient’s dental health. He might be losing his insurance soon, and may want to maximize his benefits while he still has them. If he is losing coverage in two years and has some large fillings that need to be replaced while he still has insurance, this may be the time to get those treatment planned and start doing a few each year until he retires.
Other items that are often not noted in the record are the amount of calculus and plaque, how good the patient’s oral hygiene is, and if there was a lot of bleeding during instrumentation or probing. All of these areas are pertinent when evaluating the overall periodontal health of the patient.
If you determine it would be best to start or continue root planing because the patient is not showing any signs of their periodontal health improving, this information will be important to know when discussing the way you have been monitoring them from one visit to the next, and why they need to have root planing even though they have been coming in every three months. If there is more than one hygienist in the office and patients are shared, it is even more critical to note these details.
There are also times when a patient may be borderline for needing root planing again, and one hygienist will note, “Patient was told they may need root planing and we will evaluate the need for this at their next three month appointment.” Now the hygienist seeing the patient at the next appointment has specific instructions to evaluate for the need to root plane, and it was already mentioned to the patient three months ago. When that patient shows up and their mouth is a bloody mess, there are not any surprises for the current hygienist or the patient, as long as the current hygienist takes the time to read the clinical notes from the last few appointments. The hygienist will go ahead and do the appointment as scheduled and will have the patient back as soon as possible to start root planing.
All of this information may also become very important to the front office when they are trying to get insurance to pay for completed procedures. The more information they have available to submit to insurance and the more current the probings are makes a difference in how easily the insurance claim is paid.
Another area that often has limited notes is what the doctor says during the periodic exam. If the doctor is going to watch an area, it should be mentioned in the clinical note. If the doctor says there is a large filling that may break down and need a crown in the future, this needs to be noted not only in the clinical note, but also on the very last line either in the area labeled “reason to return” or “next visit”. There should always be a reason for a patient to return, even if it is to evaluate tissue around the crown on tooth #14, as this will be used to help create value in future hygiene appointments.
Do yourself a favor, go into the office tomorrow and read your clinical notes. Do they create value in the hygiene appointment? If you were new to the practice, would you be able to pick up that patient’s chart and know exactly what is going on now and in the future? Are all of the hygienists in your practice writing standardized clinical notes based on a template or office protocol?
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