Dental Charts & Costly Mistakes

09 Dec Dental Charts & Costly Mistakes

With the judge and jury watching Dr. Roy Shelburne’s every move, he explained why he did not write the reason for treatment in his dental chart notes. You see, Dr. Shelburne learned the hard way. Here’s what you should know before you end up in prison.

Prison? Yes, prison. Nearly two years for Roy. Two years of his life. Gone.

There is not enough time to go into every detail of his case, but let me highlight some of the pearls from Dr. Shelburne and I’s interview. For those interested in more details, click here to watch our interview on my YouTube channel. There is way more in the interview; it will be worth your time, and it may save you from doing some time. But, here is a snippet about writing great dental chart notes. These tips include most of Roy’s and a couple of mine.

Charting Rules:

1. If it is not in the dental chart notes, it did not happen.

2. If you think you don’t have time, you might have a lot of time when you no longer have a dental license.

3. If you think you don’t have time to write good chart notes, delegate those tasks to a dental assistant or dental hygienist, and then go back and check them before you sign it.

4. This part of the dentistry job is tedious , and your time is precious. But, it has to be done. Use computer templates to hasten the process, and have team members chart as much as possible. Always review their initial notes, edit as needed, and only sign off on them once reviewed. Training is essential before you delegate this task.

5. Tell the patient’s story. Include what happened at the front desk to what happened and what was said in the operatory. Every team member must be trained in how to document information in the medical chart.

6. Ensure all dental team members understand how to write great, specific notes. Empower them to suggest edits to the templates as needed for the good of the entire dental practice. Even perform a chart audit periodically to help one another write complete and legally comprehensive notes. Use this time as a learning opportunity for all dental team members.

7. Have a double check system. I know many of you have seen a patient and there were no notes left regarding the previous appointment. The uh-oh moment arises. A bit of panic occurs and then the piecing the puzzle together game begins. There are mental lapses. We get busy. Charts get filed. Out of sight, out of mind. This cannot happen. There must be a two-tiered system in place to catch any unentered chart notes. The natural people to do this are the front office staff people or a designated dental assistant and her back-up person if she is out of the office. Credible, consistent chart notes are THAT important. They cannot be forgotten.

8. Take only medically necessary radiographs and know how to document what you did. (See the ADA’s latest recommendations for what is medically necessary).

Many times, it is the dentist who fails to follow through with the task of writing up chart notes. I know. I have my stacks. I have my lists. I have my treatment plans to write up. I have to do it! Plan a designated time frame for note completion. Have all chart notes up to date by Friday or Monday, so that notes only lag momentarily if at all. Empower the dental office manager to hold you to task. Make it easy on the team, and simply get them done. I was not always so efficient. I have evolved to charting at the end of the appointments when my assistants are giving post op instructions. They have typically entered in the notes along the way or while I am with another patient or with a hygienist. None of us like to stay late to enter chart notes. This system ensures it gets done, and it gets done in a timely manner. Extensive charting needs to be flagged, and written at the end of the day or at a non-clinical time.

Dr. Roy Shelburne speaks nationally about this topic because it not only pertains to a dentist’s well being, but it was deals with how we get paid from insurance companies. Dr. Shelburne keeps us all up-to-date on this topic. It’s a must see for front office insurance billers. It’s also for dentists who want to sleep better at night knowing they are doing things right…and can rest assured knowing they will not be doing any time. What a great team continuing education opportunity–go see Roy’s lecture and let him help train the whole dental team.

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