Straight From The Chart

by Kelli Swanson Jaecks, RDH, BS

It’s one of those days. The patients all arrive 10 minutes early and take 10 minutes longer in your chair. The doctor runs late to your operatory for exams. It feels like complicated case after complicated case comes through your door. Nothing goes as planned or expected. Your sharpest instruments are now dull, and you realize you’re most likely going to miss the start of your daughter’s soccer game due to the accumulated mess that needs to be cleaned up. Your fingers are aching, your brain is fried, and your charting is not done. Wouldn’t it be nice to chart how you feel, or chart how you would unload about a particular patient to your spouse or friend (withholding a name of course!)?

Chart Note: “Gums are a bloody mess! Thick, heavy gunk everywhere! Food, plaque, you name it! Patient doesn’t do a darn thing to help his situation. He says he flosses and brushes daily, but I don’t think so! It’s absolutely gross in there! Patient complained and flinched the whole time, even when I wasn’t touching his gums! Whine, whine, whine ... Doesn’t he know if he took better care of his gums they wouldn’t hurt?”

Fortunately, we usually let our better selves take over in these highly stressful and fatiguing situations, and enter something like this ...

Chart Note: “Generalized, heavy, thick plaque at all margins and interproximal surfaces. Generalized, easy, heavy bleeding. Patient very sensitive to scaling. Used topical dentinal desensitizer prior to treatment. Patient noncompliant with home care. Discussed need for daily interproximal cleaning. Dispensed home-care aids with instruction. Answered all questions patient had.”

Nice, professional, clear and concise - easy to read and understand. Any other hygienist could read the chart note and have a clear, accurate picture of what went on with this patient.

Of course, this would only be a portion of the chart notes, as other important information has to be recorded such as health history, services received, and what’s next on the treatment plan.

Remembering that busy day ...

Considering the litigious society we live in, our charting is increasingly important. Charts should tell the story of each patient in your office. If you or your dentist/employer is ever sued, your chart notes will be your only record of what happened that day with that particular patient in your office. Your memory and the patient’s memory are the only other factors, and memory is subjective. A written document in ink is much more objective and convincing than simply trying to remember what happened. It is easy for patients to sue; it literally costs them nothing unless they lose the case. Charting accurately and professionally will be your best defense.

For example, let’s say a suit is brought against you claiming negligence and emotional trauma. The defendant alleges you never told her that she had periodontal disease and was at risk of losing her teeth. She claims you never told her that her 20-year smoking habit directly and negatively affects her gum tissue. She files this suit after seeing you for a cleaning two years ago. She had subsequently moved to another town where she had to have all her teeth extracted and a full set of dentures made. You are called in for a deposition.

Now, you know you spoke with her about smoking and periodontal disease. You remember showing her charts and diagrams on the disease process. You always address potential risks and healing factors associated with nicotine consumption.

However, she claims you never addressed any of these issues and, in fact, just polished her teeth, gave her a toothbrush, and sent her on her way. Remember, you saw her on a busy day, in a busy month, at a busy practice ... a busy two years ago! Who do you think has the best memory of that day? Busy you ... or the patient who alleges personal injury? Who do you think a judge or jury might think has a clearer remembrance of that day? It sounds ludicrous, but this type of situation happens daily across our litigious country. Innocent practitioners are accused and their very livelihood threatened.

Remember, it is easy for a patient to sue. Being innocent doesn’t guarantee a happy outcome. Simply being accused of malpractice gets the attention of your state dental board, and often the attention of the public. It can take years to change a negative reputation, however undeserved. Again, charting accurately and professionally is your best defense.

Keeping it consistent ...

It is important to have consistency within an office regarding the charts. Here are some basics for good record keeping:

• Keep it clear, correct, concise, and complete.
• Keep a separate chart for each patient.
• Keep it neat, well organized, and easy to read.
• All entries and signatures should be in ink.
• Regarding electronic charting, what is on your hard drive is the original.

Although a hygienist’s scope of practice may differ according to the state one lives in, charting is a universal element in all dental hygienists’ job descriptions. What are the essential elements of a good dental chart ... one that would hold up in a court of law?

Each chart should include:

• Medical/dental history
• Radiographs
• Hard and soft tissue examinations
• Supporting clinical exams: periodontal chartings, bleeding points, plaque indexes
• Treatment plan
• Treatment progress notes
• Post-treatment records

Many different systems are taught in dental and dental hygiene schools about charting. We all go through extensive charting protocols and requirements while in training. Where you practice and from which institution you received your education will help determine both your comfort level and style of charting. However, the bottom line is that the entire dental team in your office must be on the same page when it comes to charting, regardless of where each of you received your training. Consistency is the key. Each chart should have the same elements, the same attention to detail, and the same organization. See the related sidebar about “The Six X’s.”

Other situations or events you need to include in your chart notes are:

• When a patient misses or “no-shows” for an appointment
• Any communication you have with a patient over the phone or email concerning their treatment
• When a patient is noncompliant
• When a patient is rude or confrontational with the staff
• When something does not go as planned during treatment or healing.

Remember, always document!

The 6 X’s system is but one example of clear and concise charting. The important thing, again, is consistency. Remember, the same elements, the same attention to detail, and the same organization in every chart. The chart tells the story. If it is not in the chart, it did not happen.

Remember the patient who is suing? You know you discussed smoking and periodontal disease with her, but did you write that in the chart? Did you record pocket depths, bleeding points, what the tissue looked like? Did you tell the patient what you saw and your professional opinion of it? Did you record that you did so? The answer to this last question may be the difference between going to trial, an acquittal, or a guilty verdict.

Chart note: “Patient reports smoking for 20+ years, 1.5 packs a day. Discussed with patient her smoking habit and how it directly correlates with her periodontal condition. Explained findings seen on X-rays and during periodontal exam. Answered all questions patient had. Patient states, ‘I don’t want to quit smoking, even if I will lose my teeth someday.’ ”

Clear, accurate charting is a mark of our professionalism and a courtesy to other dental health providers. Charting tells the story of each patient, allowing you to report what goes on under your watch. Let us be diligent in this aspect of our practice, providing documentation that is a clear representation of the facts.

The author gratefully acknowledges Chris Verbiest of Dentists Benefits Insurance Company for sharing his knowledge and expertise.

Kelli Swanson Jaecks, RDH, BS, practices in a general dental office and holds a LAP permit. Kelli was a 2003 winner of Butler/RDH Healthy Gums Healthy Life Award of Distinction. She is active on both the component and state level of Oregon Dental Hygienists’ Association, serving as president to her component and on the government relations council. You can reach her at [email protected].

Here is one example that is simple and concise, making room for all the elements of good charting. It’s called The Six X’s.

• Hx: History
• Ex: Examinations
• Dx: Diagnosis
• Tx: Treatment
• Rx: Prescriptions and OTC recommendations
• Nx: What happens next?

Hx: Why is the patient here? What is the chief complaint? What are the changes in health history or medications?

Ex: When we looked at the hard and soft tissues, what did we see and what did we find? Active decay, periodontal disease, lesions, broken teeth, healthy pink tissue?

Dx: Documentation of diagnosis and all diagnostic testing, including radiographs. Did the patient receive educational literature? Was there discussion about future treatment needs? (Hygienists cannot legally diagnose; however, suspected disease and findings should always be documented.)

Tx: What did we do and what did we use to do it? Take note of all restorative materials used. Was anesthetic given, how much, where, and what type? What services were rendered?

Rx: Were there drugs prescribed? What were they? Record date, name, quantity, and strength. Were any drugs dispensed from the office?

Nx: What needs to be done next? What is the sequencing of the treatment plan? Was there a referral made? To whom?