Oral Cancer Awareness month is a time to bring awareness to the importance of oral cancer screening and how you could save a patient’s life by taking the time to check for any abnormalities in the mouth. You are the oral health physician and it is up to you to make sure you have a protocol in place for the clinical screening, the referral and the documentation. Do you have all these in place? If not, I would highly recommend you re-watch our webinar with PerioLinks founder, Kathryn Gilliam. CLICK HERE to be directed.
I am going to take few minutes of your time to educate you on creating consistent and thorough clinical notes in your Dentrix software because that is what I specialize in. The Dentrix clinical note templates can guide you with questions and prompts to outlining a complete oral cancer screening so you and your team do not miss any of the documentation details. If you are handwriting all your notes, then you have an opportunity to miss something or not do it at all.
My recommendation is to include the OCS in your periodic exam or your hygiene template, so you do not have to open a different note template. This can save you time and then it is all included in the same paragraph like you did when you had a paper chart.
Here are a few prompts you could add into your clinical note template:
- OCS performed today:
- Yes – visual screening
- Yes – Velscope used (or other screening tool)
- Yes – both visual and Velscope
- No screening today
- OCS findings
- No abnormal findings
- Abnormal findings referred to ______
- Abnormal findings, recommended in-office biopsy
- No screening today
Your clinical note documentation is part of your legal record and needs to contain information to protect you, your patients and your license. For help creating your customized templates, join our community or schedule a one-on-one session with Dayna today.
