Every day more dentists make the inevitable transition to electronic dental records (EDR) and use of charting templates. There are some definite pros and cons to using charting templates. Let’s take a quick look at each:
Pro’s
•Help you quickly document a ton of pertinent negative findings and other information (i.e. documentation of medical necessity) that is reported for most patients•Provide for uniform formatting, minimized spelling/ grammatical errors
•Makes charting so simple your assistants can do much of it
•Is easier to read than your handwriting
•Provides for timely documentation
Con’s
•They need to be modified from patient to patient to account for what actually happened – people forget to make needed changes•Because they look ‘canned’ they often lack the feeling of authenticity and believability
•It is easy to cut and paste the wrong information into the wrong patient record
•Most EDR’s include templates. However, those templates are almost always (grossly) inadequate. They are a framework for you to add to and should never be used ‘as-is’.
The Pro’s speak for themselves. Let’s discuss how to minimize errors related to these Con’s.
First, the only perfect templates are those you create. You can purchase templates from a number of resources (I’ll gladly sell you some). However, no template is perfect until you have tweaked it to suit your needs. Purchased templates often provide an excellent framework from which to put your templates together.
Second, it is essential to train your staff on how to use the templates. They need to know how to plug them in, how to change the information in them once they have been plugged in, and how to create addendums when they make mistakes.
Third, this is especially important if you delegate recordkeeping to your staff; dentists must implement audit processes to look back and monitor the use and accuracy of clinical charting. It is essential you periodically review your clinical notes against your billing records to ensure each support the other. Every year countless dentists pay recoupments to insurance companies – monies paid to those providers for procedures not documented as provided.
I once worked with a dentist who routinely billed for prophies and fluoride all the while his hygienists’ clinical notes never stated she actually provided the procedures. An insurance company audited his records and filed a criminal complaint against him, prosecuting him for fraud. That’s right, a flawed template caused the dentist a boatload of legal troubles.
What’s more shocking is that I shared this with another dentist recently. Afterward, we randomly selected one of his records and discovered he had the exact problem. Glad we caught that situation.
Lastly, it is my experience that documenting non-clinical information, while not clinically relevant, adds believability, a greater sense of reliability, and helps tell the story of what happened. Most patients who file complaints against their dentist never voice their concern to the dentist, so documenting patient behavior, compliance with treatment (or the lack thereof), missed/ late appointments, and et cetera can paint (in advance of a complaint) quite a picture in your favor.
In closing – remember four things:
1.ABU (Always Be Updating) your templates.2.ABT (Always Be Training) your staff how to use templates and how to correct inevitable errors.
3.TBM (Trust But Monitor) how your templates are used and on an ongoing basis compare your clinical notes against your billing records to verify that one supports the other
4.If you need help set aside your pride and get help right away – waiting can cost you EVERYTHING!