It is amazing how many dentists will spend enormous amounts of time every day writing, editing and reviewing poorly scribbled, hard to read handwritten notes but will not do a little planning and take a few hours to create digital notes so they never have to write in a chart again.
Digital progress notes are:
- More complete
- Easier to read
- Take much less time to create than paper entries, and
You most likely already have all the technology you need to start using them. You just haven’t taken the time to set it up.
Here is a sample clinical note for a crown prep. NOTE: This complete note can be added to the record instantly when the procedure is set complete. No one needs to touch a keyboard.
Crown Preparation: Treatment options, alternatives and complications explained to patient; patient understands and consents to treatment. Reason for crown: Remaining tooth structure is unable to support a direct restoration. Rev HH, Topical placed, 1 Carp. Arti 4% 1:100 epi, Shade: XXX .RD Placed. Prep tooth remove alloy and decay. Flowable base, condition 8 sec. Optibond solo plus, flow. Light cured for 30 seconds. Laser troughing for impression. 0.8W Cont wv. safety glasses worn. Oppos. imp. Bite regist. mousse. onlay Imp.PVS. Custim luxatemp set w/ tempbond clear light cured. No complications. P.O. Instuc. rto prn. N.V. set crown.
The digital notes are far more complete than you used to do by hand. And…you can read them! Now all the dentist or team member needs to do is enter variable information such as the number of carpules or the shade, delete anything that does not apply (maybe you didn’t use the laser this time) and add any complications or unusual situations.
Notice that one of the last parts of the note says, “No complications.” If in fact there are no complications it is good to note that, however this phrase also acts as a reminder. If there was a complication this is your cue to delete “No complications” and type or click in the details of any complications that you experienced.
Dentists and dental team members continue to find excuses not to use digital treatment notes. In the final analysis most often the problem is they just won’t take the time to set it up.
There may be small inefficiencies with digital notes. Sometimes you have to erase a standard entry or add a complication. However those small issues still take far less time and effort than we spend every day writing paper notes from scratch for every procedure.
Set a goal to be using 100% pre-written digital notes in three months, July 1, 2018. Start with 2-3 hours of training for both the dentist and the staff then dedicate another 2-3 hours to write and set up the standard notes and complications.
The 4-6 hours you devote to this now will be re-paid in less than a month.