Recently, I was asked to put together a course on dental charts. This is an area that is in great flux today. While many dentists are currently going to paperless/computer-generated charting, the vast majority still use paper charts. A new dentist transitioning a practice is tempted to make the change to electronic records while installing new equipment. When I reviewed the records of a number of practices, I found most were in sorry shape - bad enough that the best move would be to fix the current charts before converting.
There are many areas where our charts can improve, and I believe we should start with the heart of the chart - the progress notes. I have looked at charts to evaluate the potential for malpractice claims. I have reviewed charts when preparing lectures on the subject, and I have examined the charts from many of my friends’ practices. For the most part, I have found all of the dental charting to be woefully inadequate.
When you transition your practice to a higher level, it is time to make certain that your charting system will ensure and document the proper care of your patients, promote the efficient operation of your practice, and provide good medical-legal protection.
The progress notes - or record of treatment - is the backbone of your patient’s chart. I have found a simple charting method that I modified from my dental school training is still the best way for me to do it 25 years after graduation! I recommend that every procedure you perform be recorded with what I refer to as the “UMODRIPS format.” The UMODRIPS format requires a chart entry under each initial of the acronym.
U - Update the medical history. I have a separate form which my staff updates and the patient signs every six months. This entry either indicates no change, refers to the signed form, or records a change in the medical history. This protects you by backing up the recorded changes in the medical history.
M - Record all medications given to the patient. This should include anesthetics, dispensed medications, and written prescriptions.
O - Write an objective statement describing the procedures you performed. You can use standard abbreviations, such as #18 MO AMAL.
D - If you have performed a procedure, you must include a diagnosis.This is the most important line of all. You might say something like, “The above procedure was performed because of ‘incipient mesial caries’ or ‘recurrent decay.’ ” Dentists often confuse treatments, conditions, and diagnosis. Remember, X-rays that may not show the existing damage to the tooth structure will be less powerful than a written diagnosis.
R - This is a report that documents the patient’s reaction to treatment. Record any unusual reaction by the patient to the treatment. Also, record any comments by the patient regarding the pre-existing conditions. Think about cases where you wished you would have recorded that a tooth was sensitive before you performed treatment on it.
I - These are the instructions you have given to the patient.This can be as simple as RPOI (Routine Post-Operative Instructions), assuming you have stored this acronym in your word processor. Another entry might be “discussed RB&A (risks, benefits, and alternatives) of treatment.” You answer the same questions over and over again. Standardize your answers and give your patients better verbal information backed up by hard copy.
P - Plan for the next appointment. This should agree with the treatment-planning page of the chart. Regular patients might be entered as “6 MO RECARE + PERIO CHART.” An emergency patient you have treated might have a notation of “RTOPRN” (return to office as needed).
S - This is the signature of the person making the chart record. Initials are probably good enough, but when you look at something years later, a signature would be better.
Most charts I see are virtually illegible, and the only heading I routinely see covered in most charts is the statement of the procedures that were performed. This is the most obvious of the entries - and also potentially the least important from a medical-legal standpoint. The most important entries are the diagnosis, patient reactions, and patient instructions. Very few doctors include these in their charts. You should! A great office should have a great charting system. You should examine your charting system for completeness, legibility, and an overall level of professionalism which supports your practice.
Dr. Michael Gradeless, a 1980 graduate of Indiana University, practices preventive dentistry in Indianapolis with an emphasis on cosmetics and implants. He is an adjunct faculty member at Indiana University, where he teaches the Pride Institute university curriculum of dental management. He also is the editor for the Indiana Dental Association. Contact him at (317) 841-3130 or e-mail to [email protected].
