Clinical notes done right

A sad story came up recently about a dentist who tried to help a patient out who had a toothache by working through their lunch hour.

Unfortunately the whole thing went pear-shaped. Now it looks like the patient might make a complaint. Naturally, in this situation, you need a great set of notes to defend the claim.

But, the dentist's notes are pretty inadequate. Probably they were rushed because it was lunch time but AHPRA doesn't care about that. They also won't cut you any slack because you bent over backwards to help the patient.

So this gets to a point I've been making to dentists for years. If you have sufficient staff the best person to make the clinical notes is a properly trained staff member.

They make the notes at the time the treatment occurs and get down everything the dentist and the patient says. If the dentist makes the notes, they are often done at the end of the day when the dentists can hardly remember what happened.

Another advantage of having staff make the clinical notes is that it frees the dentist to see more patients. The hour a day (or more!) that clinical notes take can instead be spent generating extra revenue.

The time it takes to properly train a staff member to make notes will repay you many times over in peace of mind and increased productivity.