Improving Communication By Delegating Chart Notes in the Dental Practice

Improving Communication By Delegating Chart Notes in the Dental Practice
By Rhonda R Savage, DDS
1. Complete Chart Documentation:
The need for complete documentation is critical. With digital records, a template is nice for completeness, but don't neglect the narrative. The staff can and should make chart entries; this increases efficiency and communication effectiveness. A thought for dentists: Don't touch the up button. What happens when you do? The patient jumps up, ready to leave the room.
Instead, doctors, verbally pass control of the patient to the assistant by saying: "Sam, you've done well today and everything went great! I'm going to put you into Sara's very capable hands. She'll finish the chart and talk with you about today's procedure and answer any questions you might have. I'll see you next time." Then the doctor gracefully exits the operatory. Sara says, "Just relax for a minute, Sam. I'm finishing your chart notes and I'll be right with you." The chart should be 90-95% complete before the patient leaves. If the chart isn't finished, the staff person needs to make a note to complete before lunch or before the end of the day.
The doctor should review and initial the record. If there's a staff error, do NOT correct the error, doctor. Also, front office staff should never correct errors. The person in question needs to correct their errors. If repeated errors occur, I'd recommend the doctor have a review privately with the staff member. Continued errors: Consider a formal sit down, corrective review.
One of the greatest frustrations of the front staff is having a patient in front of them, and they can't check the patient out.
2. Incomplete or Delayed Chart entries:
All chart entries need to be completed that day. There's no way you can remember more than a morning or an afternoon.
All entries should be noted in chronological fashion. The entries need to be timely, legible, and outlines all of the dental treatment. There should be no gaps in the entries. If you still work with paper charts, do not leave empty lines. Cross them through (once) and initial the cross out.
Your chart entries should detail all care, communication, prescriptions, missed appointments, re-care attempts, instructions and refusals. Financial arrangements should also be documented. One of the chief triggers of claims or state licensing complaints follow pursuit of a past due account.
If it didn't get documented, it didn't happen. Your chart is your number one communication tool. To increase communication, facilitate teamwork and refine your business systems.
Dr. Rhonda Savage is the CEO for Miles Global, an internationally known consulting business. To speak with Dr. Savage about your practice concerns, call 877-343-0909. For more details please Visit our website at http://www.MilesGlobal.net.
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