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  dayna@raedentalmanagement.com 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!


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.


2 comments:

  1. Is there a way to find out if a clinical note was ever edited, which part of the note was edited and when and by who?
    Thanks

    ReplyDelete
    Replies
    1. Dentrix currently does not have a feature to track changes to the clinical notes. If the clinical note is signed or has been locked up the only way to edit it would be in the form of an addendum. Go to the Dentrix MyVoice page to submit an enhancement request if you want this feature added to the software.
      Thank you,
      Dayna

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