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Professional News Articles : FRONT DESK by Mary M. Byers, CAE : Chart it well

Chart it well

May 12, 2009

Charting takes time—but well-kept charts also save time in the long run. That’s why it’s essential to take the time to complete patient charts as you move through your day. To start, when patients come to the office, be sure to update:

  • Phone numbers, including home, office and cell (if applicable). Ask which number is the preferred contact number.
  • Current address.
  • E-mail address. Determine if this can/should be used for appointment reminders.
  • In the operatory, update medical history and medications.

Document patient comments and what your staff spoke to each patient about. Abide by the “If it is not written, it was not said” philosophy of patient charting. Thorough records are the best defense for unhappy patients, especially those who decide to hire an attorney to handle their unhappiness. Records should include:

  • Recommended treatment plan and alternatives.
  • Indication that consequences of not completing treatment were discussed.
  • Patient agreement that questions were answered to their satisfaction.
  • Informed consent signed by patient after the diagnosis and treatment consultation.
  • Written estimate of treatment cost.

When patients decline treatment, be sure to note the reason why in the chart. This prevents the “No One Told Me Syndrome” that often occurs when there is a dispute. Reasons should be specific as possible, such as:

  • Need to talk to partner or spouse
  • Will call back after checking schedule
  • Want a second opinion
  • Financial concerns
  • Afraid to have treatment completed

Many practices also include personal notes in patient files. Milestones and accomplishments may be noted, as well as new pets, vacations, special plans, losses, etc. It makes it easier for a dentist to reconnect with a patient when he or she can begin the exchange with, “Last time you were in you were preparing for your daughter’s wedding. Obviously, you survived. How did everything go?” Though it takes just a minute to jot a personal note in the file, the reward is great in terms of loyalty when patients recognize your thoughtfulness.

If your office is working toward going green and becoming paperless, many chart forms can be customized for patients and signed electronically via a signature device like those used in retail stores. These electronic signatures are legal and binding and show compliance regarding informed consent, HIPPA, etc. Signatures are also helpful when treatment is declined.

Your office should have a uniform policy regarding what is documented and how it is recorded in the chart. Remember, a patient chart can be a friend or enemy depending on what’s in it if you’re ever taken to court. Take time now to complete charts accurately and you’ll save time in the long run.

CDS presents Front Desk, a column addressing problems dentists and staff members experience in the office. Front Desk is prepared by Mary M. Byers, CAE, a professional speaker and freelance writer. Ms. Byers may be reached at mbyers@marybyers.com or www.marybyers.com. Send suggestions for topics to be covered to review@cds.org.

© 2009, Chicago Dental Society