Treatment notes tell a story

April 1, 2002
Treatment notes sometimes are considered a necessary evil.

By Beverly Maguire, RDH

Treatment notes sometimes are considered a necessary evil. An important part of the treatment visit, the notes provide the documentation needed for legal protection, as well as effective follow-up in the care of our patients. Too often, I've seen assistants and hygienists facing a stack of charts at the end of the day, trying to recall the treatment dispensed and the details regarding the status of the patient.

Important protocols continually are added to the hygiene visit each year. A daunting task is to find the time for everything that is important: reviewing health history and medications; monitoring blood pressure; periodontal charting; assessing the restorative and perio needs; educating patients on restorative options and therapy needs; and reviewing and coaching self-care protocols.

We haven't even mentioned yet the clinical services scheduled to be provided. Treatment notes also require our prompt and immediate attention.

In restorative dentistry, the focus of most appointments – apart from the comprehensive or emergency exam – is a specific procedure. It could be a filling, crown, bridge, root canal, etc., but the visit has a definite endpoint that is scheduled for completion. By comparison, the hygiene visit involves a number of procedures and assigning priority can be overwhelming. Is the priority a "cleaning

One tool is often overlooked. The story told by the history of treatment notes recorded over time reveals a great deal of important information. Screening charts by reviewing the entire history of hygiene treatment may provide the insight necessary to guide priorities. I suggest reviewing the hygiene treatment notes from the time the patient began care in your office to the present time. In most cases, the notes reveal inadequate home-care efforts by patients, along with consistent bleeding and often-irregular hygiene visits. It's interesting to note that the conscientious efforts of hygienists to provide thorough and "more frequent cleanings" were not enough over the years to turn the tide of the disease process.

You all know the definition of insanity; it's "doing the same thing over and over while expecting different results." If what we've done (and patients have failed to do) over time has not produced health and stability as indicated by no bleeding, pockets, or bone loss, why not change our approach? I've reviewed hundreds of charts across the country, and it is obvious that things need to change. The first and most obvious step is being aware of these patterns and then committing to diagnosing disease. Aggressive hygiene treatment interrupts this unconscious pattern on both the part of the patient and the professional. Treating disease vs. "cleaning disease" wakes patients up.

Holding patients to higher standards of health is not unrealistic. Patients can be very healthy; little or no bleeding upon probing and during provocation is a realistic goal. Home care presents the most challenge in our treatment of patients. Look at the patterns revealed by the treatment notes in your patient charts. Review the oldest X-rays in a patient chart and compare them to current films. Has the patient lost bone over the years while under your care?

Take the time to research the treatment notes in your own practice. You'll find that the notes reveal a predictable pattern. Many patients have never achieved stability or health. Perhaps it's time to re-evaluate our standards and protocols that have kept this pattern in place. As Albert Einstein said, "The significant problems we face cannot be solved by the same level of thinking we used when we created them."

Beverly Maguire, RDH, is a practicing dental hygienist. She is president and founder of Perio Advocates, a hygiene consulting company based in Littleton, Colo. She can be reached at (303) 730-8529 or by email at [email protected].

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