Decoding Dental Charting
Rants from the Dental Operatory: Is it just me or does writing up charts suck? I mean, we spent all this time and money to learn how to treat and heal the dental aliments of the masses and I spend half my time doing non-dental treatment tasks. I shouldn’t complain too much…. thanks to dental practice management software, now we can create templates and just fill in the blanks…..and let’s face it, our assistants probably chart most of it…..but it is still busy work reviewing everything and adding personalized notes to each patient…. it always seems to keep me at the office longer than what I thought I’d be. I’m old enough to remember when you had to actually hand write the notes in the chart and I would always break out in a cold sweat when I would have to document something that I couldn’t spell. But I felt…. because I am a smarty pants doctor now…that I HAVE to use the proper scientific words. Like, it’s so much easier to say their “gums were red and puffy”….but no, we have to write the “gingiva appears erythematous and edematous”. Patients expect this because any loud-mouthed toddler can look and tell them that their gums are red and puffy…..but, if WE are charging you $75 to evaluate it….you paid for the big-ticket words. So, begrudgingly, we document everything to satisfy their expectation of a medical report and enough fancy and flowery language to protect ourselves in this litigious society we live in and keep it on a professional level. BUT…….ladies, don’t your wish you could chart some of the things that you really observe or feel? I know for myself…….certain phrases….can have an additional meaning behind it. For example…..when you have that patient who comes in with a “sensitive tooth” and there is no cavity, no recession, no cracks, no problems with occlusion, normal pulpal test and essentially looks like a perfectly formed typodont tooth….but they complain that it is SO SENSITIVE……so you just slather it with some Duraphat and end your chart notation with “will continue to monitor”. This basically means…I have no freakin clue what is wrong with this tooth and I am giving up on it today and I am hoping this will appease the patient because it is probably all in their head, but in case it doesn’t, I am keeping myself legally safe as I am not saying that there is NOTHING wrong with it…. just that there is nothing wrong with it that I can figure out today. A few more of my favorite “read between the lines phrases” are…..
“difficult to isolate” = 37 rubber dams and a diagnosis of xerostomia couldn’t have kept this prep dry and when the filling falls out…don’t be surprised
“specialized patient management” = they will treat the office like they are at the Hilton and request two pillows for lower back support and one additional one for their neck and only room-temp purified water to rinse with and cannot be reclined more than 45 degrees and at some point will ask to change rooms because they don’t like the view out of this operatory window
“orally defensive” = this is one of my favorites because it can be used in so many ways but essentially I mean that their tongue is the size of a buffalos or they have chapped tight pinching lips or their huge masseter muscles inhibits the access to the facials of any maxillary posterior teeth and you break a sweat trying to pull the cheeks back or they have an uncontrollable hair trigger gag reflex if anything goes more posterior than the canines….. or any other oral weapon they use to try and impede your ability to do your job
“challenging to anesthetize” = unless you want to do 17 IAN blocks and waste 60 minutes of the 45-minute appointment trying to get them numb, get out the big guns right away and the trifecta of local anesthetics and jack them up good with a cocktail of lido, septo and mepivacaine…. It’s happy hour somewhere
“patient informed of risks and consequences of refusing treatment recommendations” = if this moron calls you on a Friday night complaining of any issues with this tooth, you WILL be charging him after hours fees and if they call as an emergency about this tooth and demand to be seen today….oh so sad for you…my next appointment available is 2020
“patient states a history of difficult extractions and high dental anxiety and may require referrals to specialists” = you WILL be referring to the specialists…I’m too old for this shit
Ahh….charting, just another creative (but legally necessary) way to make our dental day fun.