Monday, February 27, 2012

Where do I make all my Notes . . . Clinical

My last three posts, including today’s, outline the most critical parts of your patient’s clinical record. Where, how, and what to document can make or break you in a malpractice lawsuit. A 2005 survey by the ADA Council on Members Insurance was designed to determine the frequency, severity, and causes of dental malpractice claims reported between 1999 and 2003. The results of this survey can be found on page 13 of the ADA Dental Practice Dental Records guide.

After reviewing this article, I found that five of the top 10 most frequent charting errors were in the clinical note section. Because this is such an important subject, I am going to help you avoid these potentially costly mistakes with the new Dentrix clinical note templates!
By using the new G4 clinical note templates, you can create a series of prompts that walk you and your team through all the required information as well as information that is important to your treatment coordinator for scheduling. The Dentrix clinical note templates are completely customized by you and, once you build one and understand the concept, you will love them. It might be a little hard to grasp the concept in a blog post, but I will do my best. If you want an info sheet that walks you through the steps using color-coded screen shots, drop me an e-mail at and I will send it to you.
The first step is to determine the templates you will need. I recommend that you create a template for the most common procedures you perform in your office such as crowns, fillings, root canals, SRP, extractions, exams, etc. You can create a template for anything, but I suggest you start here. Next, pull out a paper chart and see what you have been writing for these procedures. This will be a good guide for you to build the text and prompts for your new electronic charting system. Next, you will need the anesthetics, materials, lab names, staff names, and any follow-up information that would go with this procedure. Once this information has all been assembled, you are ready to build your first template.

From the patient chart, click on the Clinical Note tab at the bottom of the screen. On the right side of the screen, find the icon called Template Setup and click on it. This will open the list of categories and default templates that are already pre-loaded in your system. Yes, Dentrix tries very hard to help us by creating default templates, but I have found that it is easier to start from scratch (sorry Dentrix programmers). When you click New Template, you will need to choose a category and give it a name, then you can start inserting the text and prompts. The left side of the box contains the text that will be inserted into the patient’s clinical note, and the right side has the prompts (questions) that you will answer to create the note. All of this can be explained in more detail with the info sheet I can send you if you request it through my e-mail.
After you have set up the template, it will show up in the list under the category you put it in. To initiate the template, just double click it. After you have gone through all the prompts (questions) on the template, the text will dump into your patient’s clinical note. Now you have the opportunity to edit the note, add any details, delete any items that don’t apply, or sign the note. The ADA does not require that you sign the note, but be sure to remember the note will be locked up when you run month end.
Consistency, efficiency, and clarity … these are the reasons why I recommend the clinical note templates!

Monday, February 20, 2012

Where do I make all my notes . . . clinical part 2

Last week, I talked about the best place to document your patient’s health history and keep track of medication lists. While today might just be a review for some of you who have been using these features, I urge you to play along because you might learn something new.  How and where to document your patient’s medical alerts and special needs is just as important as the health history, but does not require the legality of being date stamped and locked down.

Medical Alerts
The most common and visual way to see the patient’s medical alerts is to use the Medical Alerts icon located within the top toolbar on the patient chart. When not in use, the icon looks like a white plus sign; when active, it turns red. This red plus will show on the patient appointment, on all core modules, and Prescriptions. The list of medical alerts is customized in the definitions under Practice Setup on the Office Manager. You have up to a maximum of 64, so make sure your list consists of true medical conditions that could affect how you treat your patient. I was working with an office recently that had been using the medical alerts list for administrative functions such as “sent to collections,” “bad debt,” “call cell,” etc. Now this office wants to go chartless and merge the medical alert list into the Questionnaire. Because of everything being dumped into the medical alerts list, they have quite a project to clean up.
Patient Alerts
When you think of clinical documentation, you might not be able to see where the patient alerts would come in handy. However, they are essential. Do you remember when you had your paper chart and at the top of the page written in bright red pen were all the things that were important to this patient?
When I am teaching an office to go chartless, I use the Medical Alerts and Patient Alerts hand-in-hand. Since you cannot write freehand in the Medical Alerts list, using the Patient Alerts gives you this freedom. Also, the Patient Alert will smack you in the face as soon as you open the chart (unlike the subtle red plus at the top of the toolbar).
In addition to expanding upon your patient’s medical conditions, I like to use Patient Alerts for personal things like “likes to rinse with warm water,” “only use pumice for polish,” “needs pillow for neck injury,” “gagger,” and so on. These little things make your patient feel comfortable and well taken care of.
In my next post, I will be tackling the most important piece of clinical documentation . . . the clinical note!

Tuesday, February 14, 2012

Where do I make all my Notes . . . Clinical

For those of you who read the previous series titled “Where do I make all my notes,” I hope that you have implemented some of the suggestions and have found that your notes are easier to find. I also hope everyone on your team now has a more clear understanding of where to make their notes so the information you want find is easily retrievable. In these next few posts, I will focus on the best places in your Dentrix software to make clinical documentation. This article will give your office some guidelines and recommendations on where to document the clinical information that is critical when treating a patient.
Do you ever find yourself searching endlessly for the patient’s most recent list of medications? What if the doctor wants to know if the patient has any allergies before the anesthetic is administered? Where does your office keep a record of prescriptions written to the patient? To whom was the patient referred for that root canal? Let’s tackle the answers to these questions one by one. Today’s blog post is going to be all about HH updates and RX lists.
Medication lists and Health History Updates
This one can get a little tricky because Dentrix still does not have a great spot for this information. Rather than complaining about all the bad spots to list current medications, I am going to give you the best spot to put it. My opinion (and I think the opinion of all dentists and hygienists out there) is that it should be included in the Health History Update. Since the medication list is part of the HH update (which is part of the legal record), it needs to be in a spot that is easily accessible, secure, and customized by the practice ... and that spot is The Questionnaire Module.
When I am helping an office transition from paper charts to electronic health records, I help them create a custom form that the hygienist fills out in the room with the patient just like she did with the paper chart. There are usually three things that must be answered:
1.      Have you had any changes in your health or surgeries since your last visit?
2.      Please list all current medications and supplements.
3.      Please list all current allergies.
These are followed by text boxes that can be filled in by the hygienist or doctor, then the form is automatically date stamped. The best part is that when the patient comes back in for his or her next visit and the clinician is filling out a new HH update form, the text boxes are automatically populated with the answers from the last visit and all the clinician has to do is edit it. This time, the form is automatically dated with today’s date and the previous form is saved and now locked, making it a secure part of the patient chart.
The Questionnaire Forms are also easily accessible since the Questionnaire Module icon is on every screen and the forms are listed in chronological order with the title Health History Update. No more searching for the most recent HH update or the one from last year. Contact me directly if you want to see some samples.

Wednesday, February 8, 2012

Insurance Claims Denied . . . again!

I don’t know about other areas of the country, but in my neck of the woods I’m hearing from offices that insurance companies are denying their claims in record numbers. Even in my own office, where we typically have only $1,500 to $3,000 in outstanding claims over 30 days, that number has climbed to more than $5,000. And there doesn’t seem to be any pattern to follow, where we could nip it in the bud with one quick fix. What I can say is that the issues I’m seeing are not being picked up with the eClaims triggers, so we as office managers and financial coordinators must troubleshoot the problems and fix them on our own. Let’s take a look at where some of the problems arise, and I will give you some suggestions on how to create a better insurance claim.
One problem I’m seeing is an increase in how often buildups are denied. In the past some doctors would place a buildup and not charge a patient for it. I think they felt they were giving patients good service by saving them some money. However, now with insurance companies reducing our provider reimbursements significantly, it makes me wonder if the doctors are now not giving away as much treatment and finally billing the buildup out to the insurance company to make up for this difference. In any case, a buildup requires a clinical narrative and in some cases an X-ray to justify the procedure. This narrative goes in the Remarks for Unusual Services box on the claim form. A good narrative should include description of the existing restoration, the current condition of that existing restoration, and the current disease of the tooth. For example — “Existing crown 10+ yrs old, ill fitting, recurrent decay, insufficient tooth structure to support new crown.”
Another problem I have seen lately is claims being denied because the address does not match in the Billing Provider box and the Treating Doctor box. If you are using two different providers in these two sections, make sure the addresses match. Go to the Provider setup on the office manager to check.
There are also some specialty boxes within the claim that need to be filled out in some situations. From the ledger double click on the insurance claim, double click on the claim information box, and this will open a new window where you can enter some pertinent information such as orthodontic banding dates, removable prosthetic information, pre-authorization numbers, and more. If we can fill out the claim completely the first time, then we can hopefully avoid the frustration of a denied claim in the future.