The notes within a patient’s chart should represent everything that was said and that occurred during the treatment of that patient. Nothing should be left out and nothing that didn’t occur should be added.
The notes are vital for remembering what has been done and said and, from a legal perspective, they are what you will rely on if there are ever problems with treatment. Treatment notes are important!
That makes the dentist the very worst person to record the notes.
The dentist is busy consulting with and treating patients. In the midst of a conversation with a patient the dentist doesn’t want to say “Hold everything while I type this into the computer.”
In practices where the dentist does the notes what I often see is that the notes are done in a rushed fashion, well after the event, maybe even at lunch time or after work.
By then the dentist’s memory has faded and the notes represent what is remembered, not necessarily what actually happened. Consequently the notes are often very abbreviated and incomplete. It is so much better to have a well trained team member write down all that is said and done as it actually occurs.
Nothing is left out and nothing that didn’t occur is added. The notes are made exactly at the time things are said and are a perfect record of what went on.
A useful by product of this approach is that the dentist will save an hour a day that can be devoted to treating patients.
One problem I often hear dentists raise is that the team cannot do it right. That’s what training is for! Train your team and coach them until they do it right. Also, create fast notes in the computer system so that things you say often can be added with a single key stroke.
If you spend 2 weeks training the team on proper note taking from then on you will save hours. A real win. You become more productive and get more accurate notes.