Details Matter – The Importance of Clinical Documentation

Although we know it, we often forget just how important clinical documentation is in the everyday life of a dental practice. This episode serves as a reminder of all the reasons why it is vital to prioritize good notes. Dr. Kuba shares about a time when a patient complained to the State Dental Board, and her documentation was suddenly under review. Due to her personal experience and the experience of others, Dr. Kuba is passionate enough about this topic to serve as a chart compliance auditor for Bethany Consulting. Together they hope to bring a positive and encouraging light to the importance of charting details. // Show hosts Bethany Petty and Dr. Reena Kuba dive into the following important topics: 

• Documentation includes all aspects of the patient appointment including conversation details, phone and electronic communication details, and everything else related to the patient. 
• Board complaints are more common than you think. Dentists do not freely disclose when they have been forced to make an appearance before the State Dental Board, but we should not assume that it is not a frequent occurrence. 
• Clinical documentation is ultimately the doctor’s responsibility, and ultimately the liability is on the doctor. 
• Be humble enough to get a second set of eyes on your charts. Seek honest feedback, and then be willing to make the necessary changes.