Good Recordkeeping Essential!

March 1, 1997
Treatment-sequencing, appointment-scheduling and chart documentation are essential elements of effective patient treatment and time management. They form a triad of recordkeeping that can make an office more organized and productive.

Carol Tekavec

Treatment-sequencing, appointment-scheduling and chart documentation are essential elements of effective patient treatment and time management. They form a triad of recordkeeping that can make an office more organized and productive.

Treatment-sequencing involves taking the time after the initial evaluation appointment to treatment plan a patient`s entire case. It probably is the most overlooked area in dentistry for increasing productivity.

A Treatment Schedule (such as Stepping Stones Form C-111L) can be a "worksheet" for efficient case-planning. Too many dentists rediagnose and rethink sequences at every patient appointment. There is no coordination of the appointment book, treatment schedule, instrument tray/tub set-ups and patient financial arrangements.

A treatment schedule should include what the dentist would like to accomplish at each visit, how long the appointment should be, treatment codes, special notes and instructions and, after the patient`s financial conference is completed, what monetary amounts should be collected at each visit. Every single appointment, from the first needed procedure through future recall, should be planned. As each part of the plan is completed, the next appointment can be scheduled. Our goal should be for every patient in the office to have an appointment, either for actual treatment or for a recall visit.

The fee for that day`s services or notations concerning any amounts to be collected are important. This information facilitates coordination of the treatment performed and the financial agreements made at the treatment conference. It ends the need for discussions around the office, tracking down another auxiliary who might know the details, looking up further information on the computer or worse, attempting to refigure fees. Fees to be charged are listed and treatment to be completed is noted.

Appointment-scheduling is the lifeblood of the office. Ten-minute time units and a separate column for each treatment room is recommended. Hygiene appointments can be scheduled on one column of the page or in a separate binder. The treatment rooms are appointed for the full time the patient will be in the office. The doctor`s time is coordinated with a column running down the center of the page. By naming treatment rooms A, B, C, D, etc., and putting these letters in the appropriate section of the doctor`s schedule, he/she knows where to be throughout the day. The doctor`s time is integrated with the treatment-room time.

The appointment book should be uncluttered and easy to read. Emergency-appointment times should be identified by the dentist and marked at the beginning of each day. The schedule should contain the most simple, but descriptive, notations possible concerning each patient`s appointment. In many cases, these are: (1) patient name, (2) phone number, (3) treatment codes, including the letter "L" to indicate a case returning from the lab and (4) premedication requirements. The Treatment Schedule and the Appointment Book always should match.

Chart documentation means progress notes. Use the "SOAP" formula when completing these: S = subjective findings, O = objective findings, A = assessment and P = procedures accomplished. Everything should be documented-i.e., date, auxiliary involved, tooth numbers, surfaces, details of treatment, provider signature, ADA codes, bases and materials used, anesthetic (including type and number of carpules), prescriptions and post-treatment instructions, complications, informed-consent forms signed and phone discussions. Legibility, notations made in ink and no erasures are essential. If incorrect information is placed on a chart, cross it out with a single line and initial the notation with the reason for the change. No "white-out" should ever be used! Detailed recordkeeping makes it possible for any person picking up any chart in the office to understand what is transpiring with that patient. Records must be that clear.

Carol Tekavec, RDH, is the author of two insurance-coding manuals, co-designer of a dental chart and a national lecturer. Contact her at (800) 548-2164 or at

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