When teaching at NYU Dental students wrote small books for notes, directly after joining the world of dentistry in a practice they started to use text messages as Dr. Studley would say!!! Are you writing a text message that leaves you open to an audit, or a malpractice issue. Don’t! Follow the list attached.
Clearly what should be in your treatment notes will vary depending on the type of procedure being documented. However, there are certain things that should be in every treatment note.
These are the five things that should be in every note:
- Documentation that the patient’s health history was reviewed and/or updated.
- Any chief complaint reported by the patient and the plan developed to address this chief complaint. Ideally this chief complaint should be documented in the patient’s own words if possible.
- What is next for the patient? For example, it could be their hygiene visit, a restorative visit, treatment at a specialist, or referral back to the office that normally manages their care if you are specialist.
- Any comments or events out of the ordinary that occurred during the patient’s visit. If it is a comment made by the patient, just like a chief complaint it should ideally be documented in their words if possible.
- A diagnosis or, at minimum, a differential diagnosis and a plan to get to a definitive diagnosis.