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Notes

Since I’ve worked at a few different offices lately, I’ve noticed vast differences among DH notes. Some are as long as a book, some as little as simply putting “Cavitron/handscale”. I sometimes think I am too detailed and was wondering what everyone elses basic outline was so that I can compare. I figured it would be a good question for new graduates as well.



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8 Answers

‘If you didn’t write it down, it didn’t happen’. That’s the new mantra for documenting an appointment..I tend to write more than less. After documenting the medical hx review, and what was done that day, I go into detail if the pt had concerns and record what the recommendations were. Also if the pt does not accept rec tx, I record that “pt understands risk of not treating: tooth fx w/ possibility of being non-restorable.” Gone are the days when it’s ok to write: ex, scl, pro. When there’s a question or dispute, you will be very glad you went into detail.

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I write a book! Some hygiene students will be working with me during summer break and they looked at my notes and said my notes are even better in detail than they are learning at school. I did go to the same school. I just know that if I’m ever on vacation or replaced the next hygienist will know everything I’ve ever said personally, professionally and clinically. I like to keep personal notes about each pt and their personal lives so they feel comfortable and remembered.

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The charting outline I use:
TX: whatever I did clinically. Ex: FMX, FM PC, adult prophy.
MHX: any changes.
OCE: was there anything of note for head, neck, and tissue exam.
Subjective: did the patient have a chief complaint or concern.
Objective: what I found concerning patients complaint or anything I saw clinically.
Then I go into the details of perio findings and what I explained to patient. Ex: gen. inflammation and bleeding, loc. sub. and supra calc. Gen. 4mm with loc. 5mm pockets. OH fair. Recommendations for treatment.

Then the details of the treatment I completed. Ex: FM US and Handscale, selective polish. Calc. was tenacious, smoothed WNL, pt. tolerated well.PARQ
NV: 6 Mo. RC

I agree with ann, You are always better off charting too much. Just stay away from subjective notes concerning the patient themselves, ex: pt. was rude and difficult to work with.

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I write everythingggg down…what I did, the results of what I found, what we talked about, and what their treatment plan is…I chart complete…I update probing…I sign off on all notes and charting…I sign off on their medical history and always verify oral cancer screening done…

I am the charter and the note taker of my office…the others do far less or none at all…but…nobody can tell me what I did or didnt do because its all right there…

I finish it off with any additional notes the Dr may add if he adds any or if he’s not in the office its noted as well…

Dr’s def appreciate the thorough work and notes…they know exactly what they’re in for 😉

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More is better, I also put in options that the Dr. gives patient for treatment. briefly ie. Dr. discussed options #14 endo and crown or ext and implant and then which patient was interested in.

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My clinical notes are similar to Sue Halverson. I agree, you cannot document too much!

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I much prefer paperless charts for notes rather than paper because I can type faster!!! I write LENGTHY notes, everything dr. discussed, homecare instructions, any and everything I see. Its true-if its not written down, it didn’t happen. Also how you write things is important. I was taught early in my career to write “pt states they took premed (name of drug and dosage) as directed” since you did not actually SEE them take the meds. I want to make sure that (god forbid) I ever get hauled into court, my notes are complete and leave nothing to the imagination.

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The office I am at has note templates according to the type of appointment being completed. So if I just did a regular prophy I click adult/pro and it gives me all the detailed fields I need to remember to enter and it can be modified by choice. Kind of nice because it allows for consistency!

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