It would seem as though doing less clinical data entry, less letter writing, less word processing, and less handwriting would be counterproductive and, more so, dangerous for the integrity of the office. Accuracy, thoroughness and completion are known to be the key elements to good clinical notes, not only for documentation purpose but also for…
Category Archives: Progress Notes
How about doing it right the first time!
Would you do something right the first time if you knew you wouldn’t have to do it over and over again? On average most doctors pick up a single comprehensive examination patient record 7 to 10 times at the following intervals: Before the patient arrives for their new patient examination During the visit to call…
Avoid the anxiety: You don’t have to BE paperless to GO paperless
There’s so much buzz about being paperless. The stressful thought of the transition is often what keeps practices from facing the inevitable until ultimately they have no choice. However, there is a much better approach to the matter. The concept of going paperless can have many different meanings and the process can unfold on multiple…
SO many things to remember…
Working in Perio, we have a lot of things to remember. We remember details about certain patient preferences. We remember questions to ask and procedures to follow. Mental checklists often become enormous and it takes a skilled professional to keep everything in check in order to perform the job thoroughly. Being away from the office…
Proper clinical documentation and associated legal risks
Some of the easiest ways to ensure your clinical notes are effective in terms of a medical legal standpoint are outlined in the following: Legibility – hand written notes are often not legible, the use of digital records eliminates this discrepancy Contemporaneous – showing the documentation was actually done at the time of the visit…
