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!


Dayna Johnson, Certified Dentrix Trainer
Dayna loves her work. She has over 25 years of experience in the dental industry, and she’s passionate about building efficient, consistent, and secure practice management systems. Dayna knows that your entire day revolves around your practice management software—the better you learn to use it, the more productive and stress-free your office will be. In 2016, Dayna founded Novonee ™, The Premier Dentrix Community, to help cultivate Dentrix super-users all over the country. Learn more from Dayna at www.novonee.com and contact Dayna at dayna@novonee.com.


No comments:

Post a Comment