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What happens if I back date a clinical note?

Your clinical note is part of your legal documentation for your patient’s chart. When I say, “legal documentation,” to me, this means that it cannot be deleted or altered without some kind of security feature in place. There are only a few places in Dentrix that I consider “part of the legal documentation” and the clinical note is one of those places. So what exactly happens to make it a secure place to make clinical notes and what happens if you need to edit a note or back date a note?

First, it is important to know that the clinical note will be locked into history if you sign the note or you run the month end process. If you need to alter the clinical note after it has been secured, the only way to do this is with an Addendum. The Addendum will attach itself directly to the original note with today’s date. After you have saved this Addendum, it is also locked up into history and cannot be altered or deleted. If you ever need to print out your patient’s clinical notes, you will see the date of entry and the date of the Addendum.

Now, there may be times when you will need to back date a note. For example, if the doctor comes in the office on the weekend to see a patient and he does not write up the clinical note on that day, he will need to back date the note. Another example might be if you forgot to write up your clinical note for a patient visit (we are all human) and you need to back date it. If you are back dating a clinical note into a month that has already been closed out, your note will automatically be secured into history. Also, if you back date a note, it will show the date it was created and the date it was backdated to. See image below.


Knowing how your clinical note documentation will present when printed is important to know if and when you need to show your clinical documentation. The Dentrix software does a great job to show the dates and times so you can feel confident in the integrity of your clinical documentation.


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Progress Notes vs. Clinical Notes

As you start to use the patient chart more and more, it is important to understand the difference between the Progress Notes tab and the Clinical Notes tab at the bottom of the patient chart module. The reason I feel it is important is because they show different things and sometimes offices get confused with the language. I also want to show you how these two modules work together and how you can make your chart review each day a lot easier.

  • Progress Notes: Progress Notes keeps track of procedure codes and the status of those procedure codes. You will also notice there are columns of information with symbols and things that I will explain. These symbols will help you visually to know if there is more information about that procedure code.
    • The Date, Tooth, Surface, Description and Provider columns are all pretty self-explanatory so I will not go into a lot of detail about these.
    • “N” column = If you see a musical note here, it means there is a note on the procedure code. I love this note box for the diagnosis and the reason why you are treatment planning that procedure. For information about this note box, CLICK HERE.
    •  “R” column = If you see a > in this box, it means this procedure has been referred out to a specialist. So it would be very common to see a musical note for the reason why along with a > for the referral. For more information about referring out treatment, CLICK HERE.
    • “D” column = If you see a D show up in this box, it means that someone has added a diagnostic code to this procedure code. Now this field is not being used very much yet because the dental industry has not yet adopted a universal diagnostic coding system and the insurance companies are not yet requiring it.
    •  “M” column = If you see a triangle in this field, it means that this procedure code has been flagged for medical cross-coding. If you see a solid triangle, it means that this code has been billed to medical. For more about medical billing, you can CLICK HERE.
    • Status = There are four statuses you will see here; EO = existing other, E = existing, TP = treatment plan and C = completed. Any procedure code that has a C in this column will match the ledger.
    • Amount = The amount you are charging the patient for the procedure.
  • Clinical Notes: The clinical notes tab is what happened today. This is where you will write up the materials used, anesthetic, next visit and anything else that happened during the appointment or anything that was discussed during the clinical portion of the visit. The clinical notes can be written using templates and signed with an electronic signature device. To read more about clinical note templates, please CLICK HERE.

One feature I think is really cool is that you can merge the Progress Notes with the Clinical Notes for an easy patient chart review. If you want to read more details on how to do this, please read my blog titled “Read your clinical notes like you used to” by CLICKING HERE.


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Protect yourself from an insurance audit with proper documentation

Have any of you been noticing your X-rays being denied more frequently than usual or have you been subject to an insurance audit on excessive X-rays? It is
happening and if you have not seen it yet, you will soon. I want you to be as prepared as possible when the insurance companies come knocking on your door.
 

When I work with dental teams, I often see the practice using the Continuing Care system in Dentrix as a way of tracking when a patient is due for his or her next series of X-rays. Your recare system is the most powerful system in your practice and it is the lifeblood of your practice. If you let patients fall through the cracks, you are letting thousands of dollars walk out the back door and your patients may suffer from unscheduled treatment. I do not doubt that your team has the best patient care at heart when you use the Continuing Care system in Dentrix as a way of staying focused on staying current on your diagnostics for your patients. However, taking X-rays is not based on the insurance frequency nor your “office policy” on BWX frequency.

Diagnostics is the reason for taking X-rays, not frequency. With this being said, your clinical documentation needs to reflect this in order to defend yourself in the case of an insurance denial or insurance company audit. I recently attended a study club meeting presented by my good friend and colleague, Teresa Duncan.  She stressed two main points in your clinical documentation.

Since I help dental practices all the time with their custom clinical note templates, there are two things you need to include in your template.  This can easily added to your clinical note template with a checkbox prompt so you can choose the variable answer for each patient.
  • X-rays were reviewed by . . .
  • X-rays are needed because of . . .

One office I know has made a new office policy that the doctor comes into the exam before the hygienist or dental assistant starts to take the X-rays so they can be properly diagnosed. I have another office that has changed up its recare appointments so that the X-rays are diagnosed at the current appointment and then scheduled with the next recare visit so they cover all their bases.

Now, I am not suggesting that you stop using the Dentrix Continuing Care system for tracking X-rays. However, I am suggesting that you add the risk assessment and diagnosis in your clinical note to substantiate the taking of the X-rays.


If you would like the full report developed by the ADA and the FDA on this topic, please email me directly and I will send it to you.

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Health History Update . . . it's about being prepared for anything

If your patient had a medical emergency and your team had to call 911, how long would it take you to pull up his or her most current medical history? Is the list of current medications and allergies buried among all your clinical notes or does your most recently scanned health history form have the words “no changes” all over it, forcing you to continue searching back to the next scanned document … only to find the words “no changes” all over this one as well. It’s not just about being prepared for an emergency … it’s about being prepared for anything.

During the time I was working in my practice full time, my doctor performed complicated surgical procedures and placed dental implants on a regular basis. We had a patient whose dental implant did not integrate and she had several complications during the healing time and, in the end, we ended up removing the implant because it was just not in the cards for her. She decided that it had been the doctor’s fault that her implant failed and I remember working with our malpractice insurance company trying to piece together all her documentation into a timeline beginning with her first visit.

In my opinion, the health history should have at minimum six pieces of critical information. If you are a more detailed clinician, there are other pieces you can add as well. Here are my top six pieces and a few alternates . . .

  1. Current medical conditions, recent surgeries and hospital visits. This should never say “no changes.” You should always have a list of what is current at this point in time. If they are diabetic last visit, they are more than likely diabetic now. List it. Don’t write “no changes.”
  2. Current prescription medications, over the counter medications and herbal supplements. If their medication list didn’t change from last time, never write “no changes.” You should have a date stamp with their current medication list every time.
  3. Current allergies, including reactions to local anesthetics. Again, if they are allergic to latex, then your health history update today should list Latex Allergy not “no changes.”
  4. Today’s BP and pulse. I had a doctor recently say to me, “I am not their medical doctor and my patients say they will leave my practice if I force them to take blood pressure.” Okay there are two parts to this comment. First, you are their oral health physician so start acting like it. Second, if your patient is going to leave you because you care, let him or her go.
  5. Emergency contact name, relationship and mobile number
  6. Physician name and contact info
  7. Tobacco use
  8. Pregnancy (this could go in #1 even though it is a temporary condition)

I love using the Questionnaire module in Dentrix because it is efficient for your clinical team. There is no scanning and you can use an iPad or tablet if you do not have a monitor in the treatment room that the patient can see. The Dentrix Questionnaire module will turn any paper form into an electronic form and the way it auto-fills information from previous appointments makes it about a 30-second task for the clinician. These electronic forms can be digitally signed and locked up into history for added security.

If you would like a sample Health History Update that I use in many offices in the Questionnaire module, email me directly at dayna@raedentalmanagement.com.

I created a video on how to create an electronic form in the Questionnaire module and you can watch it by CLICKING HERE. 

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Hygienists . . . you are one of the primary educators in the practice

We all know that research shows the systemic links between oral health and the rest of the body, especially the relationship between periodontal disease, cardiovascular disease, diabetes and respiratory disease. As oral health providers, it is our responsibility to educate our patients about the significance of periodontal disease and how it will affect the rest of their body.

One of the tools you have as a hygienist is the Dentrix perio chart module, but do you know everything that it will do to help you with visual aids for educating your patients? Let me show you a few of my favorite things you can do with your perio chart.

  1. Use the Graphic Chart to show your patient what a 9mm pocket looks like or where there is a lot of bleeding. You can enlarge a specific quadrant or arch to show specific areas in more detail by clicking on the + in the corners and center of the graphic chart. You can also click on the Show Options button to include the data measurements.
  2. If you want to show your patient any changes in their perio chart, you can compare up to four exams at a time. I would recommend only comparing two exams at a time because then it will show you a colored arrow if the pocket depth got better or worse (a green arrow means it got better and a red arrow means it got worse).
  3. You can print both of these two visual aids for your patient to take home.



As the hygienist, you are one of the primary educators in the practice. Use the tools you have in your software to enhance the case acceptance for perio therapy and help your patients work toward a healthy lifestyle. These diagnostic techniques are extremely important to getting your claims paid, but far more important is educating your patients about the link between other oral health and systemic diseases.

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What if your lab cases were linked to the patient chart . . . would you be interested?


There is so much more that goes into going paperless than eliminating your paper chart. Since launching my Path to Paperless coaching and presentation, I have watched the digital landscape evolve significantly. With the addition of the HIPAA Security Rule in 2005, dramatic changes had to occur in order for the dental practice to become compliant with the exchange of electronically protected health information. To this day, many dental practices are still not compliant with the HIPAA Security Rule.

One of the most challenging information exchanges is in the form of images and digital impressions to your lab. My goals is to find solutions that are have a user-friendly interface for the team, seamless integration into your practice management software, and a low-cost price tagfor the office. I found that with DDX. This web-based software solution has it all.

When I found out that DDX is woven right in to the Dentrix Patient Chart, Document Center, and Lab Case Manager, I knew I had to get the word out. Here are some of the ways DDX and Dentrix talk to each other.
  • You will get a new tab at the bottom of your Dentrix Chart, along with the Progress Notes and Clinical Notes tabs. This gives you and your team easy access to your digital lab files.
  • When you create a lab case, DDX automatically creates a clinical note in the patient’s chart, avoiding any missed documentation.
  • DDX is fully integrated with the Dentrix Lab Case Manager for better case management and scheduling.
  • All lab case summaries are automatically entered into the Document Center as a PDF file. This makes it easily accessible for review or transferring to another provider.

If you are using Dentrix G5 or higher, you have probably seen the DDX icon on your tool bar and wondered what it does. If this is a solution you or your doctors are looking for in your practice, CLICK HERE to learn more.

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Best Practices for your team . . . daily



I have written many articles in my blog about all the different reports you should be looking at and the different statistics that are important to keep your eye on … but what is the “best practice” for these reports? Who should be looking at them and when? In the next three weeks, my goal is to give a guideline for these questions. I will be breaking it down into a daily, weekly, and monthly format and what each team member should be monitoring in his or her department.
This first week of the series, we are going to start with what you need to be looking at on a daily basis. 
·        Front Office or Back Office – Someone on the team needs to be looking at the daysheet and matching it up to what was scheduled for the day. This can be the office manager looking at the whole day or break it up with the dental assistant and hygienists looking at their own column of patients. You are looking to make sure that every patient who came in had the correct procedures posted and that nothing else was accidently set as “complete.”
·        Back Office – The clinical team needs to make sure that there was a clinical note written for every patient you saw in your chair that day. If you are chartless, the easiest way to do this is to filter the view with completed work and clinical notes in the patient chart on the progress notes tab. For more on this, CLICK HERE for more information.
·        Office Manager – There are a couple of management statistics I would check on a daily basis because it will make reviewing the monthly numbers a whole lot easier if you have monitored it throughout the month. All these numbers can be found on the Daily Huddle Report, CLICK HERE for more information.
o   New Patients – Make sure every new patient who is entered has a referral source so your doctor knows how the patients are finding his or her office. Also, this is a good time to write out your thank you notes to referral sources and your new patients.
o   Case Acceptance – How much was diagnosed vs. how much was scheduled? If this is low, check to see if the treatment plan was scheduled and not marked as completed.
o   Collections - If collections for the day were low, why?
o   Production – Are you on track for the month?
If you look at these numbers on a daily basis, then you will have a much better chance for success of meeting your monthly goals. You also have time to make adjustments in your schedule and systems if you don’t wait to the last minute.

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Get creative with your patient chart


When you are traveling down the path to paperless, the computer IS your patient chart and the clinical documentation becomes one of the most important pieces of the puzzle. You no longer have your blue and red indelible pencils to draw in the existing fillings, put Xs on the missing teeth, and mark up the tooth chart the way you want it. The goal with an electronic chart is to make it look as accurate as possible so when you are discussing the treatment plan or when the doctor walks in for the exam, there are no assumptions and there is no misguided information.

Let’s get a little creative and learn some of the tips and tricks you can do with your Dentrix software to make the patient chart look as accurate as possible.

Remember when you were treatment planning that occlusal pit composite filling or the MOD that covered the entire mesial cusp and you could get out your colored pencils and color away? You can do the same thing in Dentrix. Just click on the Cusps/Pits button and select the paint type you want. If the filling has already been treatment planned and you want to change the look of the filling, just right click and click on Edit Surface Painting.

Remember in the paper chart you could pick up your pencil and draw in a lingual bar retainer or circle something you wanted to remember? With the Chart Notations, you can do exactly that. On the tool bar, select the Chart Notations icon and then select the color and size of pen you want. Use your mouse to freehand draw on the tooth chart. If you want to erase your drawings, then select the eraser tool.

What about the patient who had 4-bi extractions during ortho when they were a teenager? You don’t want it to look like they have missing teeth. What about the patient who has a large diastema between 8 and 9? Using Conditions can create a visual picture of the patient’s mouth. Here are some common conditions to use:
1.      Drifting Mesial– Use this for missing teeth when the space has been closed. This paint type will put arrows to show the space has been closed.

2.      Open Contact – Use this for diastemas and open space between teeth

3.      Unerupted – Use this condition when the tooth is below the gum line. Using this condition will also cause the perio chart to skip the tooth.

Here are some other blog posts on clinical charting:
CLICK HERE for video on treatment options
CLICK HERE for a great way to review clinical notes

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