The Journey to Hygiene Excellence: Part Three

Dec. 21, 2006
Weather the storms and avoid detours: Systemize your data collection and documentation

By Nancy Dukes, RDH

Certainly any successful and pleasurable journey — whether through life, toward wellness, or just for pleasure — requires organization, planning, and follow-through. Quality comprehensive care for patients requires a behind-the-scenes system of data collection and documentation. As health-care providers, we invite our patients to accompany us on a journey to wellness, and we must therefore be responsible for fulfilling that commitment through professionalism.

When it comes to the patient's dental health, health-care providers provide the road map for the patient's lifelong journey. Patients trust that we will always act in their best interest. To provide excellent care, we must be committed not only to communication with our patients, but also communication among ourselves. We know the way to do this is through data collection and documentation. If it is ever incomplete or nonexistent, we know this can cause difficulties for the patient and clinicians or business administrators. So how can we avoid stress created by lack of excellent documentation?

As clinicians, one of our most important roles is to communicate, in written form, our comprehensive evaluation of patients. The complete record contains a description of the patient's original condition, the data collected, comprehensive periodontal charting, diagnostic quality radiographs, necessary photographs, the diagnosis and treatment plan, the detailed progress notes on the treatment and results of the treatment. It should also contain the patient's personal data, health history with updates, treatment estimate, financial arrangement and informed consent documentation. This record provides for excellent scheduling, patient education, enhanced case acceptance, enhanced retention, accurate financial arrangements and a reliable documentation of sound clinical judgment.

The patient record documents treatment from the comprehensive evaluation to completion (this is the road map) and outcome, along with lasting effects of treatment through continual evaluation. Complete charting includes documentation for clinical, legal, insurance and forensic purposes. Once a patient leaves the practice, the documentation is all that remains of the events regarding their care. It must be done accurately and thoroughly. Anything less and you could be headed for unpredicted stormy conditions.

The record must be organized logically and in language that is comprehensible to all. Continuity among clinicians is of utmost importance. This includes not just method or technique, but also thoroughness of content. If you are operating on anything less, you are surely feeling the stress of stormy conditions in the form of disorganization, confusion, and strained team member relationships. While there is no universally required charting system, there are a few simple rules that every dental professional should follow.

• One chart per patient

• Patient's complete name clearly written on every page

• Every entry dated

• Every entry written in ink and signed

• Use only abbreviations documented in the office manual

• Every contact with the patient should be documented (phone, fax, e-mail, etc.)

• Documentation of all prescriptions

• Documentation of all referrals and the reason for the referral

• Documentation of chief complaint in the patient's words

• Documentation of diagnosis and treatment plan including the reason

Any dental professional, even one who is not a member of your team or familiar with the case, should be able to read the record with ease and understand the patient's problems, treatment alternatives, why a particular course of treatment was chosen and what the next step should be.

A patient's chart should read like a book, beginning with the foundational information and following through to the most recent contact with the patient. Only necessary information should be kept in the chart. The most current information should be readily available to avoid searching through a chart to piece together a patient history. Documentation that was once necessary but no longer current (such as old radiographs) should be placed in an envelope for easy access and to prevent clutter in the chart. This is excellent time management and stress control.

If your office uses paper documents, color-code them for easy retrieval. If your office has made a commitment to paperless, the entire team should be trained to enter and retrieve all information. A complete, accurate record is the most reliable source of evidence that you have acted in the best interest of the patient. It also allows us as clinicians to provide the very best long-term care without having to reconstruct the patient's history at every visit. This equates to comprehensive evaluation, comprehensive treatment planning and comprehensive dentistry.

Sound records provide an objective, factual measure of treatment and a solid basis for selecting a particular treatment option. Malpractice allegations remain subjective until they can be substantiated. If a patient has been treated within the standard of care, the complete, detailed records should demonstrate this. Accurate, exact charting must become a fundamental goal of the practice without exception. A system that meets all of the requirements yet is user friendly must be developed. Remember in the legal system, if it is not written, it never happened. Jurors tend to place greater credibility upon written records rather than testimony of the doctor or patient. This could make a huge difference should a defense ever be necessary.

Documentation for insurance purposes adds a slightly different dimension to patient record keeping. In order to provide the documentation needed to obtain payment from dental plans, chart notes must document the necessity of the treatment recommended and rendered. Radiographs and/or photos are often necessary for diagnosis and documentation. Periodontal charting is also an important documentation and diagnostic tool. When a claim is submitted with a narrative, the chart and narrative must communicate the same information. Do your records always meet this requirement?

It is imperative to properly code completed procedures using CDT procedure codes. Exactly what procedure was performed and coded should be documented accordingly. Anything different could constitute insurance fraud according to the experts. Remember, a procedure is not a procedure until it is completed. Insurance companies track the total number of times each provider submits a code. Tracking information is used to determine, in the insurer's opinion, whether a code is being overused or used improperly. If either is suspected, further documentation may be requested and refunds have been known to be required. This is a detour that you do not want to encounter in your journey to wellness with your patient. Records are the practice's only defense. Well documented diagnoses and treatment plans are critical.

The success of the dental practice and patient depends on our ability to communicate. Documentation is our means of communicating internally. So how can we do this well without being totally overwhelmed by the process (paperwork/computer entries)? The answer can be in the development of documentation template protocols. The entire team should be involved in the process to customize the protocol to not only meet the requirements, but also the specific needs of the practice and patients. These templates would then be followed for each of the practice standard procedures. Samples of each template should be on record in the Practice Standard Operating Procedures Manual. Organization and attention to detail in chart organization not only saves time, it saves lives, ensures meeting the standard of care and protects the practice legally.

A doctor has the duty to properly diagnose and formulate a treatment plan that is discussed with the patient. This must be documented in the chart. The doctor does not have a duty to convince a patient to undergo recommended treatment. That decision is the responsibility of the patient. Comprehensive documentation is proof that you are providing evidence-based care. Clear diagnosis and a course of treatment based on well documented findings leaves little room for doubt.

According to risk management experts, there are three areas which must be discussed with every patient.

• The nature of the treatment

• The risks, complications and benefits of treatment, including likelihood of success

• Alternatives (including no treatment) with the risks, complications and benefits

Templates satisfy documentation requirements for all three, while providing excellent records of the patient appointment.

The patient record is a statement of what has taken place. What you record reflects your values, beliefs and professionalism. Following well-established protocols will provide for excellent patient care, follow-up and practice legal protection. This will allow your practice to focus on the well being of the patient and the delivery of comprehensive quality care, instead of weathering storms and avoiding detours on the journey to wellness.

Jameson Management, Inc.'s Nancy Dukes, BA, RDH, invites you to expand your horizons in the area of patient motivation by joining in a series of articles to discover the keys that will enable you to book more passengers than ever imagined on the journey to wellness. The Journey to Hygiene Excellence not only features this Wellness Approach to Clinical Care article, but also features on Comprehensive Health Evaluation; Systemizing Your Data Collection and Documentation; Treatment Planning and ADA Coding; Building Relationships of Trust through Effective Patient Education; Case Presentation and Treatment Acceptance; and Building Retention and Referrals while Offering a Healthy New Patient Flow. Dukes is director of clinical consulting for Jameson Management, Inc., an international dental practice management consulting firm. Visit and call (877) 369-5558 for more information.