I teach the principle that “if it is not documented, it did not happen”. While this principle is still very relevant there are new concerns… You documented it, but was it really necessary? Did the condition really exist? Did you really do the work?
More practices today are use electronic dental records. There are certainly pros and cons of doing so, which is beyond the scope of this blog post. What is important is that the software used today allows providers to template their notes, which are often necessarily-detailed. The problem with using templates, especially those with pre-populated answers are whether the answers accurately reflect the patient presentation, diagnostic test results (i.e. x-rays), the dentist’s findings/recommendations, and (ultimately) treatments provided. If yes, great! If no, oh no!
Because of the heavy documentation burden placed on dentists’ shoulders dentists often favor the use of charting templates. However, it is important to know and appreciate the risks. Failure to appreciate the risks is tantamount to handling a venomous snake without a healthy appreciation the snake can KILL you or inflict severe pain.
In dentistry, as with other parts of healthcare, there are clinical requirements and regulatory requirements. It sure seems there should be a relationship between the two, but such is not necessarily (always) the case. Many dental professionals fail to understand these parts exist. Others don’t care. Either way, now you know.
Sometimes you have to document certain information because the rule or law says you have to even though it has no clinical relevance. Sometimes you need to document information because it is clinically relevant and is not related to any rule or regulation. Support your clinical thought processes and decisions to be used for later judgment, especially when you deviate from acceptable standards of practice (if you dare), this documentation (not your later testimony) may be the only thing to save your bacon. Here the “if it is not documented, it did not happen” idea is relevant.
Every patient encounter is a story. Every part of every encounter needs to be addressed so it clear why the patient presented, when they presented, what condition(s) they presented with, and how they presented. Simply – Who? What? When? Where? When? Why? How?
Dentists and their staff (key element) using templates must go through the template when applied to a patient record to review each element, delete what doesn’t apply (or make sense) and modify what is necessary to ensure the story of the patient encounter clearly and accurately details of the patient encounter.
The only thing worse than not telling the whole story of the patient encounter (omission) is telling the wrong story (commission). “False documentation of patient care is not just bad patient care; it’s illegal.” – Kathleen Sebelius, former Secretary of Health and Human Services
So, which lie would you be willing to go to jail for? None? Prove it.
Pay close attention to your clinical and billing records, minimize errors, educate (and re-educate) your staff, set expectations, provide for quality assurance/quality control processes and measure your progress continually.
Be well. Do good. Be blessed.