10 Tips on Writing Excellent Treatment Notes
Understand Your Patient and Treatment
- 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.
- 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.
- 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.
- 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.
- Chart diagnosis and rationale for treatment. This should include pertinent facts and details that lead to a definitive diagnosis.
- 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.
- Describe any handouts or other resources that were provided or reviewed, and any instructions that were given before and after treatment.
- 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.
- 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.
- Document patient no shows, any elements of non-compliance, and consider including patient interactions with staff during phone calls or other conversations.
