In discussing documentation in our modern digital offices, let me be very clear that I’m a huge fan of the “paperless office.” I was a proponent of replacing the paper charts and x-ray chemicals with digital versions from the first time I saw the possibilities. However, as with every new tool in our office, we need to enjoy our exciting new products while maintaining our boring old standards of quality. One of those old standards of quality is good solid documentation, and it’s beginning to slip in a serious way in many digital offices. Going to a “paperless” office is a big time saver and an excellent marketing tool, but it’s also become a way for sloppy documentation to creep into our office habits. Aside from making the office seem scattered and disorganized, a lack of documentation can have severe legal ramifications. Even the best of doctors can get sued for malpractice: and while I make no claim to being a legal expert, every expert with whom I’ve spoken mentions good documentation as your best defense should you ever face this horrible prospect. Let’s look at the places where we need to examine documentation in our offices:
- THE INITIAL PHONE CALL – I think we can all agree that this initial contact with our office is vital to our relationship with patients and parents. We hire people with excellent phone skills and we train them to get all the preliminary information we need while creating a good first impression. Yet even when they do all this, a lack of documentation can trip us up. It’s great that the receptionist found out who the patient saw for a first opinion and what patient and parental concerns exist regarding treatment……but when our receptionist “keeps it all in her head,” we frequently never learn what we could be doing to “WOW” this family. And why did she neglect to share that useful information? It could be that we never showed her where to type in a few simple comments so that the treatment coordinator and doctor would see them prior to the initial appointment. It could also be that we never impressed upon her the importance of those conversational comments. Whatever the reason, we need to instruct our front desk staff to document anything interesting or informative from that initial conversation. And we need to be sure they know how and where to make those notes. Documenting those comments for future reference gives us a valuable insight into the concerns of a new patient, and also lets our patients know that we really care about what they have to say.
- THE HEALTH HISTORY – We sometimes tend not to consider the heath history when discussing our shortcomings in documentation, but we should. Although the patient or parent fills it out (thus doing the documenting) the doctor needs to review it, discuss any pertinent health information and then sign or annotate it, showing that it has been reviewed. With our new digital technologies, some histories are sent right from the patient’s desktop to our software, some are filled out on a tablet PC and all the rest get immediately scanned into the patient’s record. Whether the doctor sits and reviews the form before it’s scanned or brings it up and reviews it on a monitor then signs off electronically, this signed or annotated documentation is essential to our patient record. A history that’s transmitted to us digitally and goes directly into the patient record is merely an existing history, not a reviewed history.
- THE INITIAL EXAM – This is one area where good documentation is absolutely vital….and it’s rapidly turning into one of the weakest areas in many paperless offices. We have great software that sets up a very detailed questionnaire for the treatment coordinator to populate as the doctor measures and diagnoses. This has proven to be a wonderful timesaver, especially appreciated by those of us who once worked strictly on paper. However, all those little checked boxes don’t cover everything that gets discussed in the initial exam. The doctor may discuss extraction versus non extraction, and the benefits of each; jaw growth and its potential to help or hinder; need for a two phase treatment; and any number of other issues relating to care and treatment options. If the treatment coordinator isn’t taking notes and maintaining a record of that conversation, it may as well have never happened. The mom will forget what was said, other staff members will be unable to answer questions intelligently, and the office has not created a solid legal record of that exam appointment.
- THE OPERATORY – Our operatory staff has also been struck by the tendency to lean too heavily on digital documentation. All of our digital software has great “drop down menus” where we can choose today’s procedures and create a plan for the next appointment. This is great stuff and an extremely useful tool, but it has to be coupled with attention to detail and diligence in documentation. If we added a procedure that wasn’t planned, it needs to be documented. If we discontinued elastics or headgear, it needs to be documented. And if the doctor or assistant had a conversation with mom to reassure her about a treatment concern, we need to document that as well. Again, we have to remember both the impression we present and the legal ramifications. If we didn’t properly document today’s appointment, we risk making the doctor and assistant look incompetent at the next appointment, as they fumble around because they set up for the wrong procedures. And when our legal record of treatment isn’t present, we have no proof the treatment was ever done.
- THE FOLLOW-UP – Good patient follow-up is also an integral part of good documentation and my advice to every office is to continue documenting to the very end of your relationship with the patient. If someone came in for an initial exam and the treatment coordinator ran all the appropriate reports and made all the appropriate phone calls, there’s still one step left for closure in the relationship. There’s a tendency after “X” number of calls or recall cards to just let the patient slip out of the system. A better format (after all other options have been exhausted) is to send an old fashioned letter thanking them for coming in and letting them know you will de-activate their record in thirty days if you don’t hear from them. This not only provides you with an office archiving protocol, but it also gives you documentation when talking with the patient’s dentist that you did everything possible to get orthodontic treatment started. This same type of letter should go out to retention patients who have been de-banded and then have subsequently gone missing. Send a letter letting them know how important you consider retention maintenance, but also stating you will deactivate their record if you don’t hear from them in a defined time period. This not only provides archived closure, it also gives the office a back up if mom calls two years later and complains because teeth have shifted and “no one told her retention maintenance appointments were needed.” Interestingly enough, this type of letter can have one additional side benefit. It sometimes prompts wayward patients and parents to pick up the phone and make an appointment. The final letter is a real win-win situation.
I certainly don’t have to tell those reading this article that we’ve always been sticklers about documentation in orthodontics, so let’s not let all our technological advances make us take a step backwards in our due diligence. A doctor for whom I worked many years ago told me “we have lots of paper, write down everything I say!” Let’s make our new caveat “we have lots of memory, get it all documented!”
