In today’s world protecting your practice from potential risk is very important. One way to protect your practice is to document, document, document! I live by the saying that if you didn’t document it, it didn’t happen. There are several places within Dentrix where you can document your interactions with patients, therefore protecting your practice.

Clinical Notes

Having detailed clinical notes can make all the difference in the world in a court of law. I recommend you make detailed notes about each procedure you complete as well as any special instructions or comments from the doctor to the patient. An example of this would be if the doctor informs the patient during a crown preparation that the decay was deep and that if they experience any sensitivity, the tooth may require a root canal. You can use Dentrix Clinical Note Templates in the Patient Chart to make writing these notes quick and easy.

Signed informed consent forms are another important part of documentation. I recommend you have patients sign consent forms for any invasive procedure, such as an extraction or a root canal. If you have specific questions about exactly which procedures require a consent form in your state, I recommend you contact your malpractice insurance company. They are usually willing to help minimize risk for their practices and can give you the information you need. You can set up customized consent forms in the Treatment Planner.

The Office Journal

One often overlooked area that I think is important to document is your correspondence with patients– both the written and verbal communication. For example, if you have attempted to contact a patient several times to schedule a filling, document those phone calls in the Office Journal. If the patient comes in for an appointment a year later, and now their treatment-planned filling has progressed into more extensive treatment like a crown, you can provide documentation that shows that you made numerous attempts to contact the them to schedule an appointment.

Treatment Plan Case Status Notes

Whenever you use the Update Case Status option in the Treatment Planner to reject treatment cases patients are choosing not to proceed with, you can add a comment about why the status is being changed. When it comes to choosing a new status for the treatment case, I recommend rejecting treatment instead of simply deleting treatment from the Patient Chart. When you reject a case, Dentrix keeps a record of the treatment plan and provides a space where you can make a note to document why the case is being rejected by the patient.

Having proper documentation can help to protect your practice and eliminate misunderstandings with your patients. When you have procedures and conversations properly documented, it removes all ambiguity and avoids arguments. I recommend setting expectations for your team of what should be documented and where they should document it in the software. Use the areas I described above to help make documentation easier for your team.

By Charlotte Skaggs, Certified Dentrix Trainer

Charlotte Skaggs is the founder of Vector Dental Consulting LLC, a practice management firm focused on taking offices to the next level. Charlotte co-owned and managed a successful dental practice with her husband for 17 years. She has a unique approach to consulting based on the perspective of a practice owner. Charlotte has been using Dentrix for almost 20 years and is a certified Dentrix trainer. Contact Charlotte at [email protected].