I have yet to check treatment notes or templates for a Dentist or Hygienist and find them anywhere close to Standard of Care stipulated in all Dental Practice Acts or the ADA Code of Ethics and Care. Simply put, we need to have templates and notes that reflect the fact that some time, some place, and somehow, we will have to defend our actions in a court of law. In this circumstance, what is written is all there is. It does not matter what you intended or “shoulda, coulda, or woulda” done, if it’s not written down, it just didn’t happen.
With this in mind, let me give you a few areas that need to be addressed that I often find lacking in most templates and notes.
o As a point of reference, every patient seen in hygiene or treated by the doctor should have a current “blood pressure reading” that is recorded in the chart. That means every time you stick someone with a needle they should have a new recorded blood pressure that day.
o Every patient must have verbal and written notation that “there is no change in medical history” every time the patient is seen for any reason, indicate there was no change and that is noted in the files. If there is a change, you must note that also.
o Every patient must have a written and verbal informed consent. I would record in the chart: “Advantages, disadvantages, risks, and alternatives were given to the patient and the patient consented to treatment.” I will send you a copy of our written informed consent if you will email me.
o Patients must have the number of carpules and actual drugs used recorded. Make sure that you take the time and create great templates for asset protection if someone sues the office. The current templates that are already in your software are not adequate for a Board intervention or lawsuit.
o Custom templates should be the same for all doctors and all hygienists. It should be a collaboration to create a template that would stand up in a court of law.
o You need written post op instructions for all procedures. This is the final part of informed consent and standard of care following a procedure.
o Every patient treated should have the phrase: “Tolerated treatment well” at the end of all templates or notes.
Michael Abernathy, DDS