A couple of weeks ago, I had a timely conversation with my good friend, Teresa Duncan, and it made me think about all the offices I have worked with that are still using the Dentrix procedure code note for clinical documentation. Now, if you have no idea what I am talking about, read on. For those of you who do know what I am talking about, you have some work to do.
Now is the time to make the transition over from the procedure note box to the Dentrix clinical note templates. Back in the day, we could create a clinical template that would post directly to the procedure code as soon as you posted it complete. Back in the day, this was the most efficient and only way you could electronically write down what happened during the visit today. It was fast, complete and easy … but it came with some critical drawbacks.
The critical drawbacks, in my opinion, were enough to switch over to the clinical note templates, but, for some of you, it seems like you need a little more convincing. Let me remind you again of these critical drawbacks of using the procedure note for your clinical documentation in case you need a refresher.
- You cannot sign a procedure note which would put a provider stamp on it and instantly lock your clinical documentation into history.
- You cannot add anything after the procedure code is in history. This happens with the month end process and, after the procedure code is in history, there is no way you can do an addendum like you can with a clinical note.
- There is no “behind the scenes” time stamp placed on the procedure note.
Now, those are important enough for you to start using the clinical note templates instead of the procedure note. However, as I learned during my conversation with Teresa, there is a new critical item that you need to know. Insurance companies are now requesting a copy of the clinical note instead of a narrative. Over the past couple of years, insurance companies have been moving away from the “Remarks for Unusual Services” box on the claim form and asking for a copy of the clinical note.
There are a couple of ways you can transition to using the clinical note instead of the procedure note for your clinical daily documentation. The easiest way to accomplish this is to edit each of your procedure codes and just change the check box in the Edit Note window from Procedure Note to Copy to Clinical Note. This will allow you to continue the same process of posting your procedures complete and the template will auto post. The only difference here is that your template will dump into the clinical note instead of the procedure note. You will still need to do the editing that you were doing in the past.
The second way you could change over would be to build new clinical note templates and copy/paste your existing templates from the procedure note and stop the auto post from happening when you set complete. This will take more time but, in my opinion, it is totally worth it.
Check out next week’s article where I will give you some tips on building the best templates ever. I also have a course in the Novonee library titled “Building Better Clinical Note Templates” where I help give you samples and recommendations based on best practices
