Clinical Notes for the Dental Team Create Credibility

Many dentists are in the dark about what is happening in the healthcare arenas surrounding their practices. As a dentist in a general practice, to remain cloistered in the “medical claims are not part of my practice” mindset is like still clinging to paper charts because you don’t like change.

Change is happening and the world of dentistry involves multidisciplinary teams in order for the patient to achieve optimum health.

What is the best way to show physicians that dentistry is integral to the total health of their patients? Communication in the form familiar to physicians that is essential to patient care.

Currently there are two standards for medical documentation created to provide unity in exchanging patient information:

S.O.A.P clinical notes and reports.
Center for Medicare and Medicaid Services or CMS for Evaluation and Management Services or EMS

https://www.cms.gov/

Many dentists tell me that they learned SOAP: Subjective, Objective, Assessment, and Plan in dental school but haven’t seen a need to apply the principals in the general practice. SOAP note format has been in the physician’s world for more than 3 decades and is standard for patient care today.

Organizing data in the SOAP format will bring credibility for communicating with other dentists, specialists and physicians involved with treating the same patient. In the world of general dentistry patients needing multidisciplinary care for TMD, Obstructive Sleep Apnea, appliance therapy, oral surgery and periodontics services are becoming more and more commonplace as the scientific data and technology have paved the way to treat these patients.
Organizing a team meeting to discuss integrating the SOAP note format in everyday charting of treatment notes will start the learning process. Insurers will often raise a red flag or denial if it is observed that the practice is using cut and paste for clinical notes so always take custom notes for each patient to insure accuracy of creating the medical necessity of the treatment.