Effective Note Taking for Dentists

dovetail-notetaking

EDR adoption in dentistry has been sluggish and uneven. Some practices have deployed EDRs successfully while others struggle with implementation. All too often, the fault lies not with the dentist or practice staff but the software itself.

Practice Management Software and EHR Systems

Like many other healthcare professionals, quite a few dental practices installed practice management software. They were good at capturing and processing data related to billing, accounting, and claims processing. But they failed dentists in the areas where it mattered – providing effective patient care.

Similar problems arose with the earliest generation of EDR systems. Many of these tools were not designed with dentists in mind. They were general purpose EHRs that dentists had to adapt to their needs. As you might expect, many clinics struggled with these IT systems.

Dedicated EDR Software

Today’s EDR systems have come a long way since then. These tools were developed for dentists and their specific practice requirements. They are able to capture more clinical data. Many EDR services offer sophisticated tools that help with data entry and retrieval. Sadly, there is one area in which EDRs still need significant improvement and that is note taking.

Patient Notes – a Mix of Paper and Digital

In spite of the advances made in EDR development, many dental practices continue to use a mix of paper and digital records. Accounting and billing data end up in the digital format most of the time with radiographs, charts, and digital photos a close second. Information that the dentist needs to provide patient care like treatment notes, chief complaint, and dental history are all on paper records.

Effective Note Taking for Dentists

Why does this still happen in 2018? There are many reasons, chief among them being that the notetaking experience in EDRs leaves a lot to be desired. Dentists want digital notes to reflect the traditional paper chart. The techniques used to record and read information from paper charts have been honed over decades of use.

Instead, they have to contend with software that forces them to enter data manually. Many dentists give up on EDR notes entirely because they don’t have the ability to customize anything. If you can’t store all the contents of a patient chart in EDRs, then why not use paper right?

EDR Shortcuts or Culprits?

EDR developers have tried to offer alternatives that alleviate some of the burdens from dentists. Templates are a common feature in most modern EDR systems. The user can create different templates for most common complaints. It speeds up note taking for a significant proportion of the patient population. With the jump to digital records, shortcuts like copy-pasting data become possible. Users can copy data from older visits instead of typing it out slowly.

However, both these features have the potential to do more harm than good. A dentist using templates or copy paste is in danger of duplicating errors into new notes. Some information might be missing because the user forgot to add the data after filling out the template. Such inaccuracies in the patient chart compromise diagnosis and treatment.

The damage doesn’t stop there either. Most dentists will face at least one or two malpractice suits over their career. In such cases, treatment notes and patient charts form a big part of the dentist’s defense. The use of templates and keywords in notes has become a central dispute in such cases. Lawyers can point to mistakes in EDR notes and question the dentist’s credibility.

EDRs have a long way to go in bridging the gap between people and technology. Fortunately, vendors are working on alternatives that allow dentists to take notes exactly the way they want.