Excellent patient records boost office efficiency; Here`s how to make your system one of the best.
Carol D. Tekavec, CDA, RDH
Today I accompanied my mother for out-patient cataract surgery at a free-standing surgery center. To attract patients, this center has spent countless dollars on advertising in our community and throughout the southern part of our state. It is a lovely place with beautiful decorations. It has all of the amenities that make you think, "Here I will receive good care." I was excited to see how the center would operate. I anticipated it as being absolutely "state-of-the-art."
The first person we encountered was the receptionist. The desk she sat behind was expansive. She wore a smile and a nice, tailored suit. She did not have on a name tag, but the sign on her desk spelled out her title.
Mom walks with a cane and has several other infirmities. She does not let these things get her down; however, she does have trouble with mobility.
After giving her name at the desk, Mom was told to take a seat, which she and I did. Within minutes of getting settled, she was called from a door several feet away. As she struggled to her feet, with me helping her, the receptionist watched from the doorway. We walked into the private office indicated, and Mom wrestled herself into another chair. The receptionist took out a chart and busied herself with the forms. She took out one form and looked at my mother and asked for her full name. Mom gave her name, which the receptionist then followed up with the question, "Now, you have Medicare, isn`t that correct?"
"No, I do not have Medicare. I have this insurance coverage," replied my mother, pulling out her medical card.
The receptionist rifled through more of the papers in the chart, searching for information. It quickly became apparent that the "insides" of this chart did not match the "outsides." The chart folder itself had a fastener at the top, but it was not being used. There were at least 20 paper forms that needed to be filed, attached, or somehow accounted for inside this chart. They were simply loose inside the folder. It did not surprise me that there was confusion as to whose chart this was. The receptionist left her desk, presumably to look for the correct chart "insides."
As I watched this transaction, other scenes involving patient charts came to my mind. I have worked in offices with brown-bag "sack" type charts, and offices that kept records on 3-by-5 cards. I have seen "Medical History" forms that consisted of 10 questions. I have seen progress-note entries that were nothing more than an abbreviation such as "Rec," with no further explanation. I have wrestled through charting files where it was impossible to see the letter labels on the outside folder. I have seen systems where charts were filed by numbers rather than by letters of the alphabet, and I have seen dental charts, like these medical charts, where nothing is fastened inside and the entire contents of the chart can wind up on the floor in the twist of a wrist.
A patient`s chart is a document of measureless value. It is not something to take lightly, either in regard to the information it documents concerning treatment-planning or for the data it contains concerning notes and billing. When the receptionist told us that she had the "insides" of someone else`s chart inside my mom`s chart "outsides," it made us wonder if the clinical treatment in the facility was as confused as the front desk. It amazed me that in this completely modern clinic, where no expense had been spared, they could not put together a chart that would stay together.
In dental offices, we face these same issues every day. While on the one hand, we may be looking forward to the day when we have a presumably "paperless" office, (how this can ever happen remains to be seen); on the other hand, we need to be able to find out what we need to know about our patients real fast and right now. The patient`s paper record is our blueprint for treatment, our legal record of what has transpired with the patient, and our legal defense in court.
With good charting forms we can communicate with one another more efficiently and with insurance companies more credibly. (At a recent meeting of dental-insurance claim consultants, I was ap- palled at the lack of detail and confusing notations I saw on the attached charting forms. In many cases, it was almost impossible to discern to what the dentist was referring. Insurance delays are a common problem for offices. Simply sending in clear forms with clearly-marked indications for treatment can go a long way toward expediting payments.)
After several more problems regarding recordkeeping de- tails, Mom had her treatment at the surgery center and we left. Luckily, her recovery was uneventful, which is not to say the same for her follow-up appointments and insurance billing. The confusion and lack of attention to detail caused my mother to seek out another physican. She will not be returning to that clinic again.
How does all of this translate into dental terms? Our patients are judging us by the way we handle all aspects of their treatment. The receptionist who watched my mother struggle in and out of chairs showed a lack of concern for her comfort. A dental patient with similar problems should be assisted in every way possible.
In addition, if we are uncertain or disorganized when it comes to dealing with basic details, such as recordkeeping, we hurt our chances to become our patients` trusted caregivers. If our patients don`t trust us, they will leave us.
What Can We Do?
Attention to basics is important to our patients. While all aspects of patient care should be as organized as possible, our patient records should be impeccable. The record should be a folder that opens, book style. The forms contained inside should be securely fastened and thoroughly completed. The forms should be easy to use for all members of the dental team. All "loose" items should be kept inside a large pocket. All forms should be updated continuously.
The Medical/Dental History form should arrange questions in alternating fashion; No/Yes, No/Yes. An answer out of sequence spotlights a possible problem quickly. A section for allergies, premedications and medical "alerts" should be included. A form that can be updated by a date and patient signature is preferred also.
The Patient Information form should simplify front-office paperwork. It should contain patient employment and insurance information. An authorization section that allows for assignment of benefits, and sections for signature on file, general consent and information release, are helpful. Worded correctly, the authorization can be photocopied and attached to an insurance-claim form.
The Progress Notes form should provide sections for all aspects of treatment. A space for the dentist`s signature is important. Everything that occurs with a patient must be written down.
An Initial Data Base and Treatment Recommendations form is necessary to document the hard-tissue portion of an exam. Base-line information, including missing teeth, with the date of extractions, present restorations, including date of completion of cast restorations and removables, and extruded or drifted teeth, is needed. Pathology, recommended treatment and prioritization also should be recorded in detail.
A Comprehensive Periodontal Examination form records probing depths, bleeding areas, recession, mobility and furcations. Space for at least six visits is helpful. Photo-copies of such a form can be used to provide documentation for insurance needs and as a communication device be-tween a general dentist and a periodontist. It saves time.
Remember:
- Recordkeeping constitutes more than 90 percent of front-office activity.
- Lost information will often delay, inconvenience or require work to be redone.
- The personnel cost to handle records often averages more than 20 times the cost of the records themselves.
- An improperly maintained record can become a lost patient or lawsuit.
In this age of third-party pressures and managed-care woes, it is imperative that we help ourselves and our patients stay together. Software programs and the like are exciting, but are not as effective for the money invested as the lowly patient record. The ADA publishes a brochure on what typifies a good patient record. A good recordkeeping system can make your practice run efficiently and lucratively. Investigate how to make your system one of the best.
The author writes a monthly column on dental insurance for Dental Economics. She is a practicing dental hygienist, the author of two insurance-coding manuals, co-designer of a dental chart and a nationally-known lecturer. She can be contacted at (800) 548-2164.
