Dental Sleep Medicine Insider November DSM Insider | Page 15

CAN ANYONE ELSE
KNOW WHAT YOU DID?
W
hat if a stranger came in,
opened up a chart in your office,
read through a treatment his-
tory, and had to certify exactly
what you were thinking about
during those patient visits? Not
what you did – the crown on
that lower right molar. What
was your assessment of the
problem? How did you connect
the patient’s chief complaint
and history to your plan to treat
them? Is it there for all to see?
In dentistry, we are used to
writing down what we did (and
for the purposes of this essay,
‘writing down’ includes “typ-
ing in”) using the codes that are
required to fill out insurance
forms. D2740 is a crown, but is
there information about why the
patient chose the crown, the his-
tory behind the pathology and
related health issues of the pa-
tient, your decision-making, and
the details of the crown materi-
al, prep, and provisionalization?
Thought not.
Recall your last visit with your
physician. Did they talk about
why you were there, discuss
your history, perform some
kind of physical exam, and make
a recommendation? That’s
what happens in nearly every
non-surgical medical visit. If
you were to look at your chart,
you’d be able to follow along
as your doctor worked her way
through the process and arrived
at a recommendation to resolve
your issue. The steps would be
clear, easy to follow, and anyone
could tell the rationale behind
the medical decision-making.
If you are using a dental software
such as Dentrix, programmed
to record procedures in dental
operatories so insurance claims
can be completed and paid, it’s
unlikely anyone looking at that
random chart would have any
idea what you were thinking or
why the code D2740 is listed. You
and your assistant did a good
job of recording what happened,
maybe a little bit about why so
the insurance company has less
reason to delay payment, but
there is much that is missing.
When you see a sleepy patient,
how do you document that
information? Does it look like
the kind of notes you are getting
STEVE CARSTENESEN, DDS
from the patients’ primary care
or sleep physician? Are there
recognizable parts that flow
from chief complaint to history
of the present illness to physical
exam to medical decision mak-
ing? Is it in a SOAP format?
If those questions are comfort-
able for you, congratulations!
If those are mystery terms, the
good news is that medical sys-
tems of documentation are not
difficult to learn and implement.
Making good records of patient
encounters can become a rou-
tine that will make you wonder
why you never wrote those
things down in the first place.
INTERESTED?
JOIN ME AT THE
NADSM SYMPOSIUM.
REGISTER NOW
DR. STEVE CARSTENSEN,
DDS, FAGD
Steve Carstensen has been
Editor-in-Chief of Dental
Sleep Practice Magazine
since 2014. He began treat-
ing sleep apnea and snor-
ing in 1988 and in that time
has been a Board Mem-
ber, Secretary-Treasurer
and President-Elect for the
AADSM.