How do you handle unclear notes on a patient’s file?

Interactions between the practitioner and the patient-related to clinical examination, ongoing  treatment, present illness, prognosis, and the diagnosis are dental records. This record-keeping is  essential for good professional practice, yet sometimes it is quite challenging. Regardless of the record form  paper or electronic that is used by the practitioner to nurse dictation, the purpose is to record the communications between  different practitioners to cover a legal obligation for the reimbursement. Consequently, accurate and  complete documentation is an effective continuum of patient care. However, no system is perfect. Many different factors contribute to the creation of  unclear notes or obscure documentation. The components in particular can be the insufficient time to  interact as well as lack of adherence to compliance.  

What are unclear notes or obscure documentation? 

A typical question is what are unclear notes or obscure documentation? Before tackling a  documentation problem, let us understand the specifics of what represents poor documentation in  the first place. In the case of a practitioner using a particular dental record, it is poor documentation if it impairs patient  treatment or evaluation. For a coder, deficits in procedure and diagnosis codes can result in the same. Moreover, if the document lacks  completeness, clarity, and fails to convey a patient problem, if it lacks sufficient specificity to address patient safety that can compromise the quality of the rendered care it will be categorized as obscure documentation. 

For instance, if a practitioner is documenting oral lesions, he/she will need to include size, shape,  color, location, consistency, distribution, history, texture for the oral lesion. These specificities  will help in the treatment of the patients who need our help. The consequences of poor  documentation are significant, they can impact things like patient safety apart from having financial repercussions. 

Benefits of good documentation: 

• Effective patient care 
• Correct diagnosis and treatment decisions 
• Medical necessity diagnostic study 
• Clear communication between other practitioners that results in apt treatment plans and quality  care 

Factors affecting poor documentation
Know-how: First and foremost, insufficient information of the dental industry can result in poor  documentation. Due to the tight schedule, it becomes difficult to provide training to providers. They  document a lot of information, still leaving behind the usage of the words needed for the highest  level of specificity. Incorporation of a modified approach for proper documentation, does not happen  by chance. It requires education in the long run. 

Time-constraint: Another fundamental requirement is the time factor at play. The priority of every practitioner is  patient care, and with that obligation, documentation can sometimes take a back seat. The number of patients  that a particular practitioner is handling per day can lead to a tug of war, giving them  insufficient time to verbalize to document the same. Spending more time with patients can help with the documentation  problem. Generally, practitioners lack motivation due to missing incentives and system  prejudices. 

Copy-paste: EHR compliance is capable of accurate documentation, but only using copy and paste of  dental records with the same assessment can impair the original thinking. Some meaningful adjustments here and there are under compliance, but blatant use of copy and paste can easily miss out on different and essential patient conditions. 

Steps to handle the problem

• HIT integrated into teaching conveys to all practitioners about what does and does not work in the  documentation. Also, it explains to them the impact and importance of documentation on the  quality of care. 
• A well-qualified and dedicated team of professionals hired can work instead of disinterested or busy  practitioners in learning the EMR tool, which will eventually increase both the monetary as well as patient satisfaction rate. 
• Identify flaws in documentation with the help of experts to deliver quality dental care. 
• The  following things can prevent errors in the documentation. Experienced professionals check things like whether the document supports the medical necessity or not,  was the diagnosis and treatment adequate, were there any deficiencies, provide remedies through revisiting EMR, and check how was the care offered post-procedure to track  the outcome? 
• Perform a gap analysis on the education of practitioners and record reviews for their growth in the long  run. Addressing the complications and comorbidities motivates the practitioners to improve  documentation as they realize the severity and risk of mortality. 
• Seek help from administrators with experience in successful documentation that result in higher reimbursement  with quality patient care.