Dental teams . . . what’s missing in your clinical note?

We are going to kick off Fourth Quarter with one of the most important clinical topics … and that is your daily entry of what happened during today’s appointment. The Dentrix clinical note templates give you everything you need so you don’t miss any of the important details. We have all heard the famous saying, “If you don’t write it down, it didn’t happen.” This is absolutely true!

In fact, I have had doctors have to pay back hundreds of thousands of dollars to insurance companies because of the lack of details in their clinical note documentation. I remember (before I started working with this practice) a pediatric dental practice that was audited by Medicaid and had to refund over $200k because of the lack of documentation. The doctor never wrote down anesthetic or the type of restoration he used. His answer was, “I only use one kind of anesthetic and only one kind of resin material.”

His casual attitude in clinical notes caused him to
almost lose his practice.

I don’t want that to happen to you so, in this blog post, I want you to start thinking about what details you might be missing in your daily progress note of patient care.

Below are some of the important details to make sure are included in your documentation . . .

  • Does your clinical documentation match what you are billing out to the patient or the insurance company? For example, if you are billing out a prophy D1110, does your clinical note say you performed a prophy? Many times, I see dental practices treating the patient with perio maintenance but billing out a prophy.
  • Are you documenting why you are taking x-rays and that the doctor is reviewing them? One thing I learned from my good friend and dental insurance expert Teresa Duncan is that you must have a diagnosis of why you are recommending x-rays for the patient. Remember, insurance frequency is not a reason to take x-rays.
  • What is next? This section is more for the admin team of appointment schedulers than clinical documentation for compliance purposes. What I find is that if the patient does not schedule his or her next visit, then the scheduling team needs a place to go to for all important details about what is next, time units, and any motivational notes to help the patient schedule.

In the next few posts, we will talk more about how the Dentrix clinical note templates and prompts can help your team outline a more comprehensive note to accomplish all the outcomes outlined above. My goal in these next few posts is to give you some recommendations on setting up a better clinical note. Stay tuned!