Foresight should be "20/20"
American journalist and writer Guy Bellamy once said, "Hindsight is an exact science." In today's hectic, fast-paced practice environment, this is a lesson often learned by professionals who fail to adequately document the treatment records of their patients. However, by adhering to a few simple, straightforward rules and by consistently documenting patient records, even the busiest practice can help protect itself from an unhappy patient or his or her assigned representative.
Patient record...
- Documentation of PARQ (or equivalent)
- Documentation of definitive diagnosis
- Chart description of treatment of services rendered
- Date and description of treatment complications
- Date and description of all radiographs, study models, and periodontal charting
- Documentation of initial health history and any updates
- Date, name of, quantity, and strength of all drugs dispensed, administered, or prescribed.
- Documentation of anesthesia
- Documentation of patient’s choice of less than optimal treatment
- Documentation of declined treatment
- Documentation of dental nexus for Rx.
While by no means exhaustive, the list above outlines some major areas of attention in a patient’s record. By consistently addressing the necessary areas of a patients record, a dental professional can eliminate or minimize treatment questions posed by a patient, an attorney, or a governing board. At DBIC, we believe foresight, and not hindsight, should be “20/20”.