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Treatment notes for patients

I received the following email:

First, I must congratulate you on such an awesome website.  It brought me a lot of encouragement, information, and helpfullness as a student and continues to do so as a practicing RDH.  Second, I'm writing to inquire if there is anywhere on your site (so much info to sift thru) about recording session notes.  In my office, both us us hygienist are new grads and we learnt very well in school the importance of keeping client progress notes in the chart.  However, when we started, we looked at all of the previous years of hygienist note keeping and just picked up the same pattern as what they used.  Everything that is required to be recorded is there EX: med history update, client concerns, soft tissue finding, procedures performed (scaling, rp, polish, fl), a quick note of any pocket depth increases, and adjunctive therapies used (irrigation, LA, etc). But still we find ourselves in a rut, writing something like MD Gen Calc 43-33 and B Max 6's, LT IP Gen Plq, Loc HVY Hem 26/27 etc. and a quick Case Type II Gen with Loc Type III in post. Sext.#4.  Just wanted to know what / how other hygienists are writing up the progress notes. 

This is how I do mine:
We use Eaglesoft as our software in our office.  I have templates set in the computer and just put it into the notes and add what I need for each patient.  This is the example for the prophy appt:

First line: Tx completed that day
Example #1: PROPHY, PERIO CHARTING -- ultrasonic, handscale, polish, OHI
Example #2: PROPHY, 4 BWx, EXAM -- ultrasonic, handscale, polish with toothpaste due to pt not liking prophy past, OHI
Example #3: CHILD PROPHY + Fl2 (straw) -- handscale, polish, OHI
Med. Hx -- I add in any changes in meds, conditions, or put in that pt. stated there were no changes. BP and pulse readings placed here.
Dental complaints or concerns: I put in here anything pt asks me or tells me is bothering them, or if they are interested in bleaching, etc.  If it is a new pt, I will ask them questions on when was last visit, history of dental visits (if they had perio tx in past, etc.)
Tissues: I put how the gingival tissues look, if they generally look the same, I will put gen. papillary inflammation or if there is a localized area I am concerned about, I will put that specific area here.
Plaque or calculus build- up: I will put what I see here, example, heavy supragingival calculus on linguals of mand. anteriors, lt stain, generalized moderate plaque -- I will add comments also if one area is hard for me to remove.  Such as -- #15M is very rough, Spent a lot of time here, check @ NA
Pocketing: On all new patients we probe first appt.  On prophy pts, I full chart on computer at least once a year.  On perio pts, I chart once a year but may spot probe areas each visit and will put that info here. I put periodontal classification here. OR 2-5 mm pockets, perio charting was recorded today, see computer -- or in this spot I will add a reminder that recording on computer is due @ NA.
OHI: I specifically put down what I discuss with pt here and any comments that pt has said.  I will add a paragraph below this here if anything else is needed to document for this pt. 
Example: hard to scale lingual of #30 due to strong tongue thrust, longer I scaled, harder it got
OR
Patient has a hard time with xrays, is a gagger
OR
Patient does NOT like mint prophy paste
NA: this is where I put down what is scheduled for next appt. 
Example: b/u pfm #14
OR
6 MRC, EXAM, XRAYS
OR
2 quads, left side , etc.

SO this is what my template comes up as:
Tx:
Med. Hx:
Dental complaints or concerns:
Tissues:
Plaque or calculus build-up:
Pocketing:
OHI:
NA:

and I just add specific info for each pt.  This also reminds me to make sure I have all these areas covered.  I have always been made "fun" of that my notes are like novels, but I don't care.  It allows me to remember what I did or what pt said or if anyone was to see a pt of mine, they know exactly what I did with this pt.  I guess you can say it's excessive but I would personally rather be safe than sorry and document everything.  I also feel comforted knowing that if anyone was to see this pt, they would not be in the dark about what happened during the last appt with me.

I am sorry, I have had to take down all interactive pages on my site due to spammers.  If you would like to contribute anything here, please email me at amyrdh@aol.com and I will add it onto the site.  Thank you for your support!

Date:

04 Sep 2003

Time:

02:19:11

Remote User:

Comments

My Example: BP: 130/85, No med hx chgs, taking BCP's and Paxil, CC: U/L molars ache occas, OCX: 1x1mm red nodule on ging mucosa inf. to #27-F, sli-mod marg redness, pkts gen 3-4mm, lt-mod calc/plaq/heme, #'s 4,5,12,13 extreme tactile sens., recmd'd Sens T.Paste, rev'd OHI, demo'd brushing gently at gumline, recmd'd Sonicare, disp'd woven floss & scraper, advised more frequent cleanings. 6MRC KIsola This varies per pt (obviously), but I follow the same pattern. I do write paragraphs, but I want it to be readable by whoever might need to read it. OCX is oral cancer exam and CC is chief concern. I also devised a form I put behind the treatment notes that enables me to see what I have already discussed/demo'd/dispensed to the patient. I could try to upload it, but Amy if you're interested in posting it on your website, you'll have to tell me how to do it and where to send it - I have never uploaded anything before. I'll try to send it to you after I send this - so be on the lookout for anything from Smilechkr@aol.com. Thanks!! Kitty Isola, RDH =^..^=

Date:

04 Sep 2003

Time:

02:49:13

Remote User:

Comments

My Example: BP: 130/85, No med hx chgs, taking BCP's and Paxil, CC: U/L molars ache occas, OCX: 1x1mm red nodule on ging mucosa inf. to #27-F, sli-mod marg redness, pkts gen 3-4mm, lt-mod calc/plaq/heme, #'s 4,5,12,13 extreme tactile sens., recmd'd Sens T.Paste, rev'd OHI, demo'd brushing gently at gumline, recmd'd Sonicare, disp'd woven floss & scraper, advised more frequent cleanings. 6MRC KIsola This varies per pt (obviously), but I follow the same pattern. I do write paragraphs, but I want it to be readable by whoever might need to read it. OCX is oral cancer exam and CC is chief concern. I also devised a form I put behind the treatment notes that enables me to see what I have already discussed/demo'd/dispensed to the patient. I could try to upload it, but Amy if you're interested in posting it on your website, you'll have to tell me how to do it and where to send it - I have never uploaded anything before. I'll try to send it to you after I send this - so be on the lookout for anything from Smilechkr@aol.com. Thanks!! Kitty Isola, RDH =^..^=

Date:

04 Sep 2003

Time:

21:37:34

Remote User:

Comments

We Use Pre-Printed Sticky notes from the Printer that we Designed: (They measure appox. 8"long 2" wide) PERIO MAINT: Reviewed Med Hx ( ) YES Changes______________ B.P.___________ Pre Med No( ) YES ( ) Amox___ Clin___ Other_____ O.C.E._________Changes_____________________ Gingival Health______________________ Cal/Plaq/ H___M___S___ OH: EX___G _____F_____P____ Bleeding: H___M___S___Irrigation___________________ Charted_____Probed______Adjuncts given______________ Areas Of Improvement needed_____________________ OHI__________________________________ P. Maint. q___mos. ALT____HERE____ N.V.________ Sensitivity_____________Anes._________ Signature_______________________________________ Right at the moment this is all that I can remember but as you can see you can customize this however you'd like and then of course Add any additional Tx notes that are deemed necessary. This just helps not having to write the exact same things 10 times a day 4 days a week,instead you can stick it to the chart and just X or Check the necessary spaces A REAL TIME SAVER !!!! :) Jackie In Michigan ~~~~~~~~~~~~

Date:

06 Sep 2003

Time:

02:08:34

Remote User:

Comments

I follow the same lines of what others have put. There is something else that depending on the patient I include. I like to have an impression of were I think this patient is at...Are they improving or deteriorating....Do I want to think about some different care approaches next time they come in For example....If no improvement at next rc consider reducing to 4 mo rc and disp rx. doxycline x21 days. Another example...refractive periodontitis advancing. Continued perio. deterioration. Patient non-compliant. Continues to defer more advanced care with a periodontist. In essence.....what is it that I want to remember to look at or do the next time that I see them. I'm gettin old and can't remember so good anymore....lol. This way when they come in on recall it helps me key in on what my previous concerns are/were.

Date:

05 Jan 2004

Time:

03:47:11

Remote User:

Comments

HHX,VITALS,EO,IO,GD(very specific)PC,TC,PE(includes PI,OHI,and recommendations such as FL,RX rinses,interproximal devices,etc.TXT(treatment today)TXN(treatment next.

Date:

18 Jan 2004

Time:

12:28:21

Remote User:

Comments

Amy, I also use Eaglesoft and have made several templates. All templates pertaining to hygiene are in green, except for the failed/cancelled hygiene which is in red. Exam by Dr.,BWX, adult pro adult pro without exam exam by Dr.,BWX,child pro/fl child pro/fl full mouth debridement RP/STC perio recare with exam by Dr. perio recare without exam sealants PRE-MED (all capitals) Each hygienist has a template with her name and license # (these are in different colors so hygienists can find them quickly) failed/cancelled hygiene (in red) Each template already has basic generic notes written in them so all I have to do is edit for that specific patient. Each hygienist adds her own signature template inside the first template. Same with the premed template that already has everything but the specific antibiotic typed in it. This has allowed our notes to be quickly edited and place in the computer very quickly and easily. Sample: exam by Dr.__, __BWX taken today, adult prophylaxis, health history updated and entered into computer, soft tissue exam with oral cancer screening, used intraoral video camera to show pt ___plaque and ___calculus, full periodontal probing updated and entered into computer, used cavitron, hand scaled and polished, OHI,(place oral care aids given and instructions here......hygienist's name and license # placed here.....__MRC advised....N.V. # 5 DO composite for example In the health history comment section I've added DOB on every patient and I put in personal comments such as children and ages etc....I use that health history for a lot of things as I know I check it EVERY time so will be more likely to see stuff there. I really love this system as I can read everyone's notes since they are typed.