In this first month of fourth quarter, we are breaking down the importance of comprehensive and detailed clinical documentation. This is critical for the protection of your doctor’s license and the communication between the back and the front office team. The beauty of the Dentrix clinical note templates is the fact that you get to build them in a way that suits your practice. You get to build them in a way where your team won’t miss any of the details, which gives you peace of mind.
In our last episode of the Novonee on the Go podcast, we had Teresa Duncan on as a guest. She talked about the importance of clinical documentation and making sure it matches up with what you are billing out to the patient and the insurance companies. One of the most important things she brings up is documenting the diagnosis for taking x-rays.
As I said before, “The insurance frequency is not a reason for taking x-rays.” You must have a reason for taking x-rays and it is as simple as adding in a check box list into your clinical note prompts. What I recommend to all my offices is to include what you took today and why. Here are some examples:
- Taken for cavity detection
- History of decay
- Dry mouth
- Periodontal disease
- Pain, sensitivity or swelling
This is one of the easiest things to implement into your clinical documentation and will be one of the most important if you are ever audited by an insurance company for x-ray use. It can happen. I have heard many times of dental practices being audited for “excessive x-rays” because the practice is billing out more x-rays than their peers in the same geographical area. Or, you can be flagged for x-rays that do not meet diagnostic quality. If you have good notes, you will be fine.
Your homework before the next article is to do a quick survey of your hygiene notes and emergency exam note templates to see where you can make small changes to the template and clinical note prompts. If you need help, we are always here.
