We all have things that interest us or challenge us, and today I would like to share with you one of those topics that I have thought about and worked to refine in myself, and that is the area of communication. To be even more specific, I would like to focus on professional communication – to think about how best to convey information, especially technical things in the world of healthcare.
Unless you have worked in a hospital setting or with dentists who have, an evidently not-uncommon entry in the average dental record is handwritten and with the intent to minimally document that treatment for a particular patient on a particular day that was provided. Sometimes, the billing record is this documentation.
How do I know this? Recently I was asked to review dental records as an expert witness in a lawsuit that occurred in another Texas city. My primary work was to provide the attorney for the dentist’s being sued a clear chronological record of events. This brings up my first fundamental point about documentation. You are not writing these things down for yourself. You are writing them for others.
We all live in the illusion that the treatment we are providing in our dental treatment room is for the most part hidden from view. Nothing actually can be further from the truth. This is just an illusion. It’s sort of the same when it comes to infection control. For the most part, how will anyone ever know if a patient, after leaving a dental office, became sick from some event within that dental office? Certainly, much of this will never be known. On the other hand, legal proofs are not the same as scientific proofs. If an expert walks through a dental office looking at infection control practices, it can be a rather simple process to show whether or not the procedures being accomplished routinely are sound. And, again, since we are talking about communication here, one of our greatest witnesses in our defense – whether regarding infection control or dental care being provided generally and even specifically in the case of a particular patient – is the dated documents of inspections and treatment.
On the other hand, there is a problem with over documentation – where the initialing of tasks performed can go overboard. For example, have you ever walked into a messy public restroom only to find on the wall an inspection sheet with initials that seems to indicate that the restroom is constantly under surveilance? I don’t see these that much anymore. My hope is that those companies have revised their procedures – because a messy room belies an inspection document every time. Also, we all know that a public restroom can be trashed at no fault of the employees working there. They just need to be informed of the problem.
The best sorts of documents within dental practices – at least in my opinion – are the notebooks or even training links on the internet that are periodically reviewed and discussed in meetings – followed by implementation of what is being learned.
Well, let’s get back to what I was tasked to do for this law firm. What would you guess was my biggest problem? Incomplete and illegible treatment entries.
Thankfully lawsuits are rare, but when they occur, with regards to the dental records, it’s really too late. Whatever you consistently do will be reflected and any attempt to alter records after the fact will make things much worse – better to show the poor records and apologize as opposed to attempting to doctor the records even though this might be tempting to do.
So now, let’s step back into the routine day-to-day documentation of treatment.
If you are writing in a physical record, even though the dental chart has the patient’s name, write the patient’s name or initials or something to identify the person you are treating. This is to protect you from the possibility that a page is removed or wrongly placed in another patient’s record. Rather than justify that this is an unnecessary step in your particular situation, I recommend you get into the habit – because your situation may change. You may work under different conditions at some other time – and the purpose of good documentation is to establish patterns that you can continue your entire career. So write the patient’s name. It doesn’t have to come first and in fact, if you see any of my treatment entries – which you might if you are working in a practice that receives communication from me, let me give you my basic outline.
First comes the date.
Next comes who this message is being sent to. If it is an entry that is not going to someone else, I skip this.
Next comes my name and I write it this way: “From Dr. Ben Young.”
So, to back up, the first line of my entry is the date, To so and so From Dr. Ben Young.
Line 2 is the patient’s name. Regarding Mr. or Mrs. Full Name
Now here’s a helpful hint if you are typing records. Check out the app entitled Evernotes. This is a cloud-based program that stores notes to include pictures, voice, everything. It has strong search capabilities as well. I can search for entries under names, words and descriptions and the rest.
Now my dental software is Eaglesoft. You might be using some other dental software, but one of the limitations I have found with Eaglesoft is that it is not easy to use as a word processor. Sure, it might be better now than before, but I find that I do better copying and pasting my entries into this program rather than writing within it. And there is a bonus benefit when I do this. If someone calls me to talk about a particular patient and I am away from the office, I can still find my entries for any patient back years. Also, when I see a patient for the first time, the patient’s name and everything from one entry can be duplicated to a new entry. Then I can change the date and erase the entry to type in a new one. But it even gets better. I can copy and past in templates for procedures that I keep in another area of the program. I have templates for examination procedures, different surgical procedures, follow-up visits and the rest. In this way I am not having to think through repetitive things from scratch.
Let me end with this.
Following the initial statement of date and names,
The next thing I write is an overall description of the procedure or procedures performed. In this way I and others don’t have to read too far down to know what it is they will be reading in some detail further down. Think of it like a title to the entry.
After this title, then next general area involves standard initial safety steps. Right now during COVID-19 restrictions I have a boiler plate on all my entries that essentially states that we are under COVID-19 restrictions. We are rinsing everyone with Peridex as a safety precaution – so I say something like Peridex prerinse. Then the result of their COVID questionnaire. COVID-19 questionnaire negative or negative with the exception of whatever it was with explanation. Etc.
Next I have vital signs. These are BP Pulse and now temperature readings. If the temperature reading is 100 or greater, then this ends the visit. I have had one patient where this happened. We had her sit for another five minutes thinking that it might have been due to her sitting in a warm car before the visit. The temperature did not change so we rescheduled. She came back another day and the reading was normal.
Next in my entry, especially for new patients have to do with addressing any medical information to include allergies and medications they may be taking. Later entries may simply state that there have been no changes to the patient’s medical status.
Following the medical section, I get to dental things. The reason I do not start with dental things ahead of medical things is simply because I want to establish that this patient is medically safe for treatment – that I consider their overall health more important than dental problems. Again, remember that my initial title to the entry will probably state what it is we are doing from a dental aspect, but now we are into the meat of the entry and trying to be organized in our approach.
The first thing I probably will write about in this dental section will be the patient’s problem or concern. We classically call this the complaint. I’m not a big fan of this term, but if used as part of convention, like using the abbreviation CC: which stands for Chief Complaint, then I have no problem because other healthcare people understand the context.
This is where the SOAP format can kick in. S stands for Subjective – what do we hear from the patient. What is the patient saying and telling us?
Oh, and by the way. If a patient is agitated and angry and loud and being rude, be very careful in your documentation not to use your own subjective terms to describe things. Don’t say the patient was very rude. This is your opinion. Rather, document by quoting the patient. The patient said, this or that. If the patient stood up and left, say this. If they threw something, you can say this as well. Just keep everything to observations – things someone would witness without adding opinions as to why they did what they did. Don’t say the patient “stormed out of the room.” Remember, this document could be used later. Also, when unusual events occur, and there are other witnesses to the events, then they also should make statements in the same manner.
Back to SOAP. The second letter is O standing for Objective. We have touched on this already. These are observations you make. These come from your examination and any tests you might include. In periodontics, the bleeding index is part of this objective area. Periodontal charting as well. Also radiographs.
Next is A standing for Assessment. This is where you come to some conclusion or diagnosis. If you can’t make a diagnosis – and sometimes no one can just yet, you can call it you impression, your opinion. That’s valid because you have training as an expert. Your opinion carries weight.
Finally, P for Plan. This might be the treatment provided that day or it might be Treatment Recommendations or Treatment Plan for the future.
Now back to my entries to other dental offices. You will not find SOAP. I keep that in my head. What you will find is that my entries follow the general outline.
Finally, the last line. And before we go there, let me tell you that the last line is important because it is easy to find. What do I mean? Let’s say you have to review a record to find something out quickly, if that thing were on the last line, how difficult would it be for you to scan pages of entries to find it?
So for me, always the last line is classically called Disposition – which means, What’s next? So that is the first word of my last line. The word is Next. What’s next? They might be returning for a post operative visit. They might need to be seen in someone else’s office on a certain date or in a certain month. When someone on my team wants to know what has happened to a patient since their last visit, they can try and ask me but I promise you I probably will not know the answer – but I do know where they ought to find it. Go to my last entry and look at the last line. It will tell you what is or was to be next.
So that’s it. I hope this has been helpful. It at least will help you read my entries that come to you.
Long ago, I decided not to send letters about patients about the treatment provided etc. The reason for my decision was primarily due to the fact that these letters coming occasionally are not as helpful to other offices as hearing about the treatment being provided as it is happening. So, my entries in my own record are sent to dental offices soon after that treatment is provided. They are shorter than report summaries and they have that last line Next. Which helps everyone know what the plan going forward is. In this way it is as if I am writing entries that can go in their office records by copying and pasting – because for the most part most offices have dental computer programs that can store this information. What I have found after years of doing this is that those dental offices that incorporate my entries into their own dental records generally do not find the need to call in order to ask where a particular patient is in care. They can go to their own dental records and find this answer.
Whether this approach is unique to me or common to specialists I have no idea. Certainly, any feedback you might have on this approach I would appreciate hearing.
So what’s next in this podcast? All I can say is that I plan to have another entry in a month or so. Stay healthy and thanks for listening.
This has been the Perio Hygienist Podcast. If you have found this information helpful, please give it a positive review and share with other like-minded hygienists, hygiene students as well as dentists and dental students. See you next time.