Are the following Chart Notes Good or Bad?

Are your clinical records good, bad or ugly?

I audit lots and lots of dental records. I like the challenges of auditing detailed records, as I have to pay close attention to identify potential documentation and billing issues. Unfortunately, and all too often, the records I have to audit are not detailed and result in a lot of red ink on my audit reports.

Common charting that I encounter looks like this:

EXAM NOTES

• Comprehensive Exam
• 2 bite wings
• 2 PA’s

TREATMENT PLAN

• Pulp/SSC #A ,B, D, E, F, J, K, L
• Ext. #C
• Sealants #S, T

TREATMENT NOTES

• Completed planned TX
• Prescription amox. And T#3
• NV: 6 mo. Recall

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