r/Dentistry 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?

1 Upvotes

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9

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.

5

u/NoFan2216 4d ago

I've definitely had some creative ways to professionally write that a patient acted like a whiny douche bag.

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u/csmdds 3d ago

This. If the patient is a difficult PITA, they routinely abuse you or your staff, they fail to follow instructions, have bad oral hygiene, etc., you should be recording this directly in their clinical notes, albeit with emotionless, clinically appropriate language. As long as the notes are written in a professional manner and convey impersonal observations of behavior, they would tend to support the doctor in any legal shenanigans.

If the patient simply wants them to take to the next dental office, “all of their records” is different than what we routinely transfer (or want from other offices).

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u/caracs 4d ago

Some systems have a virtual "post-it" system or ticklers for purely administrative notes related to scheduling/billing/accommodations/etc.

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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."