If you have read one of my recent articles you understand that treatment planning and case presentation play a huge roll in your efforts to collect money at the time of service. Providing your patient with a written estimate outlining their treatment and estimated costs is an absolute must in the dental practice. But did you realize that lack of Treatment Planning is the #1 record keeping error among dental offices according to a 2005 survey conducted by the ADA Council on Member Insurance? With this in mind, Treatment Planning in the dental practice becomes not only a necessity for collections but a legal issue if the chart is ever subpoenaed in a malpractice case.
Now you might be asking yourself “How does this apply to the Front Office? It is the doctors and hygienists responsibility to make the treatment plan and document it in the chart, not mine.” Yes, I do agree with you that they are creating the treatment plan and discussing the clinical aspects of it with the patient, however, after the treatment plan is entered into your patients chart it now becomes your responsibility to manage it and that is my focus today. In this day of electronic record keeping, managing the patient’s treatment plan takes on a few new details that the office manager and treatment coordinators need to adhere to. You play a key role in keeping your doctors head above water in the case of a patient complaint or malpractice case.
There are three key elements that you as treatment coordinators need to be aware of when managing your patient’s treatment plan.
- Keeping Track of Patient Referrals – If your doctor is referring a patient to a specialist for anything it needs to be documented in your patient’s clinical record. Yes, it would be noted in the clinical notes for the day, but I also recommend it is included in the treatment plan as well. The reason I recommend this is because the treatment coordinators will be working off of Unscheduled Treatment Reports and Referral Reports to follow up with their patients not searching through clinical notes. When the procedure that is being referred out is added to the treatment plan and you note on the procedure code where the patient is being referred to, now the treatment coordinators have a way of following up with the patient.
- Managing Treatment Options – Have you ever had a patient call up years later after having treatment in your office and say something link this; “I was talking to my neighbor the other day and his dentist gave him the choice of either having a root canal or having his tooth pulled, my doctor never told me I could have had a root canal done, he just extracted it!” One of the major mistakes in clinical charting is the lack of documentation when giving the patient treatment options. When the doctor is consulting with a patient and discussing the option for example; a bridge, implant or partial, this not only needs to be documented in the clinical note but also needs to be laid out in the patient’s treatment plan options. This is where the treatment coordinators need to be careful because what I see happen all too often is when a patient decides on one course of treatment then the other options get’s deleted forever. Once something is deleted from the electronic record it is gone and if you needed to retrieve these treatment options for future use this could pose a huge problem.
- Documenting the Status of Treatment – How many times do you have a patient come in with a tooth ache needing a root canal when your doctor had treatment planned a small occlusal filling just a year ago? Then the patient says “Well nobody told me, if I knew I needed a filling I would have scheduled it, now I need a root canal!” This could potentially lead to a patient complaint or legal situation if there is no documentation to show any follow up with the patient. Part of your weekly management routine as the treatment coordinator is patient follow-up and keeping your doctors schedule full. However, it doesn’t stop there. You must document your conversations with patients somewhere in your patient’s clinical record. If you are using an electronic health record there needs to be a consistent place where you are keeping notes that are easily retrievable for everyone in the office. Remember . . . if it didn’t get written down, it didn’t happen.
The treatment coordinators have a very important role in keeping our patients clinical record accurate, well documented and safe from potential legal problems. If a patient files a complaint and the patient’s record is subpoenaed but you have a good record keeping system the potential it will go any further is greatly decreased.