The Difference Between Clinical Chart Notes and Written Narratives for Insurance Companies

By Belle DuCharme, RDA, CDPMA

There is much confusion over how to chart clinical observations, diagnosis and treatment and then edit it into a narrative for the insurance company. Narratives need to be short (about 80-150 characters) but clinical notes can be as long and detailed as the doctor wants. A narrative that is longer than 80 words including punctuation should be attached to the claim on a separate document. It is recommended that the dentists use the SOAP format: Subjective, Objective, Assessment, Plan to organize their observations, diagnosis and treatment plans.

Clinical Chart Notes:

Clinical notes can be added through some computer software using templates that can be customized for each patient encounter. If you are still using paper charts the SOAP format is easy to use. Using the same narratives for similar procedures on different patients is not recommended and can be a red flag to payors. Each charting must be unique to the situation of that patient.

SOAP format would identify:

Subjective: What is the patient telling you about their symptoms or “chief complaint”? This should be recorded in detail to closely match the patients’ words.

Objective: What do the clinicians see when observing the patient? They write down symptoms and patient responses to questions, any diagnosis or observations the dentist makes should then be recorded.

Assessment: From the subjective and the objective a diagnosis is completed with prognosis determined.

Plan: A written treatment plan is constructed to present to the patient with options and informed consent.

Patients’ clinical notes are a legal document. Dental clinical staff therefore have a responsibility to accurately chart all present teeth and past treatment, all treatment options discussed. Also updating medical history, keeping correspondence with specialists, retain consent forms and accurate progress notes.

Notes should always be recorded during and directly after the patient’s visit to maintain accuracy.

Example of clinical notes: –Pt presents broken tooth from biting down on nut shell, pain to cold–UL #14 fractured buccal/lingual cusp, and 50% of tooth left so advised patient that a full crown is the best option. Explained differences between gold and porcelain bonded crown, advised patient that PFM was the most aesthetic option, but gold is slightly stronger and helps periodontal condition. Patient concerned about crown blending in with existing dental work, concerned about metal becoming visible due to gingival recession(past experience). Discussed option of Lava crown (metal free), patient shown photographs of Lava crowns, patient wishes to proceed with Lava crown.

Limited eval, 1 PA taken of UL14 , PA shows bone to be stable no pathology. Prognosis: excellent, Pt. given verbal and written estimates and consent form to sign.

Who’s Accountable?

Although the dental assistant should record as much accurate information as possible, the dentist is responsible for the content and must check that the notes are satisfactory and make any necessary additions or amendments.

Dental assistants(or front office) can then select CDT codes that reflect what was done that date to be entered on the patient’s ledger to create a dental claim.

Example of Narrative for Crown #14 D2740 Porcelain/Ceramic Substrate (Lava)

Narrative: #14 had exist. old(15 years) MODL comp rest fail with fracture of Distal/Ling cusp. Decay undermg remng restoration. 50% tooth remng/50% lost. #14 cold sen. Bone healthy/no perio/ crown best for bite/ function.

Create narrative:

EXISTING RESTORATION :Size: LARGE/SMALL, Restorative Material: composite, amalgam, gold____
SURFACE/SURFACES-modb, mif, or_____
CONDITION—fractured DB cusp, leaking M margin, hole in occlusal of crown, prior endo (and when endo was final), decay undermining
AGE OF RESTORATION OR DATE OF INITIAL PLACEMENT ( answer in box on claim)
AMOUNT OF REMAINING TOOTH STRUCTURE—1/3 natural tooth or____
AMOUNT OF LOST TOOTH STRUCTURE—2/3 natural tooth lost or_____
PATHOLOGY/SYMPTOMS– PAIN—HOT/COLD/BITING/AIR/NIGHT/DAY –DECAY-NEW OR RECURRENT—LOCATION OF DECAY—md, bl, _____
OBSERVATIONS NOT VISIBLE IN THE X-RAY. TAKE INTRAORAL PHOTOS-if possible-or draw a picture CHART LOCATIONS OF FRACTURES, CRACKS showing extensive lines
CRACKED TOOTH SYNDROME, SEVERE CRAZE LINES ON ANTERIOR TEETH, WASHED OUT EXISTING COMPOSITE RESTORATIONS
CHART PERIODONTAL FINDINGS :. ADEQUATE BONE SUPPORT FOR CROWN / BRIDGE
ABSENCE OF PERIAPICAL or PERIODONTAL PATHOLOGY IN X-RAY
BRUXISM CAUSING BREAKDOWN OF PERIODONTAL SYSTEM