10 Tips on Writing Excellent Treatment Notes

Understand Your Patient and Treatment

1. Please understand the importance of proper documentation. It’s important to know that if a treatment element was not recorded in your treatment notes, it could be argued in a legal setting that the omitted portion did not occur.

2. Ensure each patient completes a Health History Form and document regular reviews and any pertinent updates that could impact dental care or overall health of the patient.

3. Document patient’s state of discomfort, chief complaint, duration, and whether the patient’s condition is improving or worsening – this is especially important during follow up appointments. Take a look at our information on SOAP Notes.

4. Document conversations that occur regarding treatment discussions, treatment options and alternatives, anticipated prognosis, patient’s preference and input, and any consent that was obtained as necessary.

5. Chart diagnosis and rationale for treatment. This should include pertinent facts and details that lead to a definitive diagnosis.

6. Provide detail as to which treatment was completed, what methods and materials were used, how it was safely performed, and who was involved in the procedure.

7. Describe any handouts or other resources that were provided or reviewed, and any instructions that were given before and after treatment.

8. Be sure to chart the day the procedure was completed. The validity of the treatment note may decrease if there is a lapse in time between treatment date and documentation date.

9. Include information regarding referrals, conversations, and consultations with specialists. This is especially important when the treatment is time sensitive or there has been a complication.

10. Document patient no shows, any elements of non-compliance, and consider including patient interactions with staff during phone calls or other conversations.