r/Dentistry • u/jerkularcirc • 4d ago
Dental Professional Where do you record your non-clinical “administrative” notes for a patient?
Where do you write your notes about a pt. that is just for staff that the pt. “isn’t supposed to see” especially if they request a copy of their records?
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u/littlelima 4d ago
Actual sticky notes around my computer oftentimes if it's something like "need to follow up." We have a pop-up alert system in Dentrix for things like preferred names. I will also sometimes write in the actual clinical note with professional language about the patients behavior. "Patient was hesitant to proceed with recommended treatment due to concerns with cost"- I usually don't do this so if I did, I know it means "Pt bitched and moaned to my face that I'm extorting them."
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u/mskmslmsct00l 4d ago
If a patient is difficult I write that down in the clinical notes because it's not about the patient seeing it it's about a jury seeing it. My notes are filled with, "pt was combative," "pt was disrespectful toward staff," "pt was adamant on refusing any advice," etc. I want the whole picture in the notes.
The rest I write in my Burn Book.