This past week, I had the amazing opportunity to present two courses at the Dentsply Sirona World 2021 and thought it would be a good time to recap the highlights of my first presentation “Five Ways to Help Protect Your Doctor’s License”. Even though I am a certified Dentrix trainer, these concepts would apply to any practice management software you are currently using. In this article, I will give specifics around the Dentrix platform. If you are using a different software, reach out to your resources for specifics.
My course was full of doctors, and I made it extremely clear that team members are typically the people executing these tasks, so it is up to the leadership to have systems in place for oversight. All of the five concepts I will be talking about revolve around the Dentrix software because it is Grand Central Station, and your documentation lives in your computer. If you are not yet chartless, then take note and use these tips when transitioning.
- The patient health history is one of the most disorganized pieces of the patient record and it needs to be cleaned up. It is critical to have a clear snapshot of your patients’ medical conditions, allergies, and a list of medications so you can treat your patient in the best way possible. There are also a few more things to consider with your health history system . . .
- Find one place to locate the patient health history information, so the team is not looking and documenting in multiple places. Redundancy will create a system of inefficiency, incorrect data, and frustration.
- The health history documentation is part of the legal record so it must have the ability to be secured with a patient signature or “locked” into history so it cannot be altered or deleted.
- Eliminate the word “no changes” from your documentation. You should always have a chronological history of your patients HHX.
- Improve your documentation for taking X-rays/images. I learned this from my good friend Teresa Duncan when she did a webinar for our members a couple years ago. These tips will help protect you against an insurance audit.
- In your clinical note make sure to write that the x-rays were reviewed by the doctor. You can build this into your template to make it easier for the team.
- Document the reason for taking X-rays. You can also build this into your clinical note template to include a list of reason such as high caries risk, smoker, diabetic, dry mouth, periodontal disease, etc. Insurance frequency is never a reason to take X-rays.
- Make sure you are performing diagnostics for periodontal disease. With more than 47% of adults having some form of periodontal disease, it is critical that you are able to educate your patients about their options. For more information on perio protocols, read one of my past articles HERE.
- Periodontal charting (pocket depth, bleeding, bone loss, etc.) should be performed at least once a year for healthy patients and more frequently for patients with active disease.
- The perio charting is also part of the patient’s legal record so it must be secured to prohibit any alterations or deletions.
- One thing I see a lot in offices is a refusal of X-rays consent form. You might have an X-ray refusal form but, at some point, you cannot continue to allow a patient to make this decision. You cannot diagnose most pathology without proper X-rays or images. If the patient continues to opt out of diagnostics, you might have to dismiss them from your practice.
- The final item on the list is making sure you are billing (coding) what you do. The documentation in the clinical note should match what gets posted to the patient ledger. If your hygienist is performing a perio maintenance, then you bill out a D4910 not a D1110.
These top five things might appear to be simple ideas and you might be thinking “well, duh!” However, you would be surprised at what I see happening in offices. The documentation (and lack thereof) I see in dental practices is why I have a presentation on this topic and why I am compelled to write this article for you. I am amazed all the time of the lack of oversight for these systems and I encourage you to hold each other accountable to protect your doctor’s license. Why? If your doctor is in jail, you don’t have a job.