Recently in Spear Digest, Dr. John Carson shared his perspective on what to include in clinical notes. As Dr. Carson mentioned, treatment notes should thoroughly record several items, including but not necessarily limited to:
- Steps that have been taken to render treatment appropriate for a patient's given health condition (e.g. medical history review)
- Type of exam performed
- Diagnosis or listing of potential diagnoses
- Amount and type of medications used and/or prescribed
- Description of the procedure
- Post-op instructions given
These items can be recorded in many ways, depending on the style, tools and skills of the practitioner. For example, with practice management software programs, ADA procedures and internal code numbers created within the software can be utilized to enter most of the above items and are simply billed as $0.00 where appropriate. Even if internal codes end up on an insurance claim form, they will simply be ignored because only ADA Current Dental Terminology (CDT) codes are recognized by insurance companies.
- Appropriate codes for the type of exam billed will tell the type of exam when the Progress Notes are printed.
- Codes created for the type of bonding material used and for restorative material brands can be entered in the same way.
- Codes for medications can be used "billed" per cartridge. A standard template note listing the ingredients can even be created that reads something like this, "1.8cc 1:100K lidocaine with epinephrine." Remember that cartridges today are now 1.7cc rather than 1.8cc because manufacturers now account for the plunger.
The Narrative Treatment Note
If using the coding system, the treatment note now becomes much more efficient. A variety of styles are possible. The most common form of the treatment note is the narrative. An example narrative for a simple problem-focused examination for a tooth that has a cavitated lesion might be:
BP: 132/86; P: 88. CC: "I have a hole in my tooth, but it doesn't hurt." #3 MO cavitated caries; no percussion sensitive, normal cold response. 1 PA tooth #3 taken; no PA pathology with lesion consistent with clinical finding. Discussed treatment options including composite, amalgam, gold, or ceramic. Patient opted for and rescheduled for MO-composite #3.
The SOAP Treatment Note
Another common notation format, which can be too complex for some situations and requires a bit more thought in its organization, is the SOAP format where:
- S = Subjective findings (i.e. what the patient tells you)
- O = Objective findings (i.e., what you see)
- A = Assessment (your diagnosis or differential diagnosis that must be ruled out)
- P = Plan or procedure performed
Following the same scenario as above, an example of a SOAP note would be:
S: "I have a hole in my tooth, but it doesn't hurt.
O: BP: 132/86; P: 88 #3 MO cavitated lesion; no percussion sensitive, normal cold response. 1 PA tooth #3 taken; no PA pathology with lesion consistent with clinical finding.
A: MO caries #3; vital pulp
P: Discussed treatment options including composite, amalgam, gold, or ceramic. Patient opted for and rescheduled for MO-composite #3.
The PTEN Treatment Note
Some dentists, especially in pediatrics, have adopted the PTEN format where:
- P = Plan for the appointment
- T = Treatment rendered
- E = Evaluation
- N = Next appointment
Following the aforementioned scenario, and example of a PTEN note would be:
P: PF exam for CC of "I have a hole in my tooth, but it doesn't hurt.
T: BP: 132/86; P: 88 Limited examination of #3. 1 PA taken. Discussed treatment options including composite, amalgam, gold, or ceramic. 1 PA tooth #3.
A: MO caries #3; vital pulp with clinical findings of: #3 MO cavitated lesion; no percussion sensitive, normal cold response; no PA pathology.
P: Patient opted for and rescheduled for MO-composite #3.
Clarity in Treatment Notes
While there may be other adequate methods of recording treatment notes, they must clearly tell a story. This includes the treatment rendered and rationale for treatment as well as any interpretation of diagnostic data. In no case, however, should the entry for this scenario about a carious lesion be limited to the common notation of years past: "1 PA. MO-A."
My personal favorite is the entry I've seen countless times when reviewing records: "DOA #3." The first thing that pops into my mind with this one is "three bodies dead on arrival." That's a far cry from clearly recording that tooth #3 was treated with a disto-occlusal amalgam restoration Treatment notes need to clearly tell a story to whoever reads them.
There are many more elements to the clinical record. In future Digest articles, I will discuss those elements.
(Click this link to read more dentistry articles by Dr. Kevin Huff.)
Kevin D. Huff, DDS, Spear Moderator and Contributing Author - www.doctorhuff.net