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.