Dental Charting

[Molar Whisperer]

I've been asked numerous times on how to write up a more effective dental record. I can't make any guarantees and this post is not intended to substitute for Risk Mgt Training. I just hope to provide insights. As stated in previous posts, I had experienced a malpractice lawsuit and a Board Complaint within a month of each other. Fortunately, those actions were resolved and so far I couldn't find anything on my record. I also have the luxury of working with and befriending a Dental Board Member at my DMO. Previously I was naive and thought as long as I do good work and communicate well to the patient, I have nothing to worry.

It is recommended that you include the 6 X's in your charting...1) Medical & Dental HX, 2) Exam 3) DX, 4) TX, 5) RX, 6) Next Visit. Another is including SOAP. My Board member colleague uses SOAP template for his fillings. He did say it doesn't matter for the Board although my attorney had recommended SOAP. I include it and the 6 X's to cover all bases.

Keep in mind that the judges and jury members have no dental knowledge. They can only base their decisions on testimony and what's on you chart. They don't know if you're thorough or aware of any patient's pre-existing conditions and compliance. Although I can't think of all scenarios, I can include some that come to mind. Please provide feedback if you feel I could add or correct anything. Some notes I like to include on:

1. Head and Neck Exam: Pt has no facial asymmetry, no lymphadenopathy, no pathology detected.
2. Intraoral Exam: No pathology, no vestibular swelling detected or ~3 mm moderately hyperkeratinized tissue Left Lateral Tongue (and provide proper followup and referral)
3. Radiographic Exam: NSF, no caries, good alveolar bone levels, no pathology detected
4. Discussions: (for high risk patients) Pt was advised of his/her deteriorating periodontal condition (or teeth due to rampant, uncontrolled caries). If pt does not comply with recommended treatment and further deterioration continues, then more teeth loss may occur beyond our control. (Be sure to document details of noncompliance and discussions at each visit or any missed appts)

Emergency visits can potentially lead to lawsuits and or Board Complaints. I like to include swelling or lack of, appropriate pulpal status for all fillings, perio status, any disease status, previous lack of compliance and missed appts, anything you can think of. Avoid tunnel vision. I had a colleague who went on a wild goose chase focusing on pt's CC of UR pain and missed #29 caries to the pulp.

For RCTs, always include pulpal and periapical dxs. "Tooth #19 pulpal necrosis with sx apical periodontitis or #14 sx irrev pulpitis with asymptomatic apical periodontitis." I have an operating microscope and I like to include "Under 8x magnification, no internal fractures, resorption, or caries detected, all canals located, all pulpal tissue removed." Afterwards, document your discussions with the pt on the tooth's fragile condition and the need for crown. To minimize instr separation, try to use reciprocating rotaries like Wave One (one time instr use), never apply pressure greater than "breaking pencil lead force," and always achieve straight line glide path access (see Cliff Ruddle and John West discussions). If you rotary instr is tipped and not in straight line access to the root apex, stop and reopen your access with a pulp shaping bur.

I hear many Board Complaints regarding crowns. Try to chart the tooth's existing conditions such as "#14 needs crown due to deteriorating coronal structures, vital pulpal reaction to colds, no vestibular or facial swelling. Tooth is strong enough to support crown." Before final cementation, take a Bitewing to verify margins.

I include (any or no) complications on anesth and the pt's condition upon dismissal. If any pt experiences paresthesia after 1 to 2 weeks, promptly refer to OMFS and document. If I had any undesirable outcomes, I will own it and try to correct it.

For routine procedures, it usually takes me less than 5 min to write up a chart. I rather spend the extra few minutes after getting burned. If anyone has different ideas and tips, please share.

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[PerioDont]

Do you use a note template when writing your charts?

 

[Molar Whisperer]

Do you use a note template when writing your charts?

Absolutely. I'm constantly changing it though. I'm hoping to learn from others too. I can paste some if you guys want. It's very easy...I just paste it and add necessary info...Usually per procedure it takes me about 3-5 min.

 

[Molar Whisperer]

Here is my NP exam template. If the pt has high risk factors that could impact my tx, I like to include NC codes like Nutritional Counseling (D1310), Tobacco Counseling (D1320), and OHI (D1330) and various caries risk assessment codes.

Pt arrived for NP exam, FMX
Reviewed Medical Conditions:
Medications Taken:
Drug Allergies:
Tobacco use:
ASA:
S- CC: none
O- Head and Neck exam: no facial asymmetry, no lymphadenopathy, no pathologic lesions
Intraoral exam: no pathologic lesions
Radiographic exam: no caries detected, good alveolar bone levels, no abnormal radiolucencies
Dental exam: No caries, no teeth defects/discoloration/staining
Perio exam: Light pink gingival color, no probings over 3 mm, no inflammation, minimal plaque, minimal calculus, minimal attachment loss
TMJ: No dysfunction
Occlusion:
A- Periodontal diagnosis: healthy gingiva with no detectable attachment loss
Caries Diagnosis: no caries
Saliva flow: normal
Caries Risk Assessment: low
Anxiety: not shown
P- Treatment Plan: prophy, recall
Discussions: Pt was fully aware of own dental and oral conditions
Referral: None
RX: None
NV: hyg recall
PARQ
DA:
Provider:

From my observations, the pt may lose or change insurance plans and go down the street to another dentist. If you find the pt having no caries and healthy gums and the other dentist finds 20+ caries and FM crowns & SRP needed or vice versa, you need to back up your findings with proper images (intraoral will help greatly) and solid records. My Board complaint was when I was at a DSO where the hyg gets production for SRP and various production codes like Arestin use. She usually probes 2 to 3 mm deeper and told the pt he needs SRP. Pt went to another practice where they told him his gums were healthy. He finds it prudent to report me instead of the hyg. The Board cleared me but slapped me with a "letter of concern" because some of the paper charting were missing, some conditions were not fully documented, and overall poorly written.

 

[Saddleshoes]

My Board complaint was when I was at a DSO where the hyg gets production for SRP and various production codes like Arestin use. She usually probes 2 to 3 mm deeper and told the pt he needs SRP. Pt went to another practice where they told him his gums were healthy. He finds it prudent to report me instead of the hyg. The Board cleared me but slapped me with a "letter of concern" because some of the paper charting were missing, some conditions were not fully documented, and overall poorly written.

Moral of the story---
Do a quick PSR as part of YOUR exam to double check the RDH probing.
Or better yet, do not direct a complete perio probing to be done until after YOU have done a PSR.