The importance of keeping good, and effective records in your Periodontal practice

Believe it or not, some periodontal practices still don’t value and prioritize effective clinical record keeping.  It’s often treated like something that we “have to do” as opposed to giving it the value that it deserves. When the act of making good medical-legal records is seen as a chore, it's easy to miss the significance of the process. 

Keeping ineffective records leads to complacency and worse yet, mistakes.  Leaving out any crucial information essentially equates to negligence in the eyes of the legal system, but that isn’t the main point of this article. 

We all know that having good medical-legal documentation can help protect you in the event of a malpractice claim, but there are some hidden benefits that are often overlooked.  These benefits can greatly improve the overall success level of your practice. 

Here are some of the often-overlooked benefits of well-done effective record-keeping that can greatly help you and your practice. 

You will know what you were thinking about 6 months ago.

(or longer)

Having a vivid recollection of the case is like taking a snapshot of things as they were in the past, enabling you to pick up on subtle changes as they affect conditions today.  

Remembering patients by name and what treatment they have received from you, goes a long way toward establishing a good rapport.  However, effective records also help you to get to know, and “remember” your patient at a more in-depth, personal level. 

This level of understanding will be revealed in how you are able to present yourself during conversations either with the patient directly or about them with the referring practice.

Remembering your patients in detail through effective record keeping can significantly influence the impression of patients and referrers to show them that you practice at a higher level of quality of care that your competitors. 

It also makes for a lot less work for you in the long run because recollection becomes effortless. 

You will have a better team.

If the staff (I used to be one of them) is required to help contribute to the process of effective clinical record-keeping and those records are clear and easy to read, they will all be better and more proficient clinicians. 

Simply put, an effective level of detail input, especially when required by everyone, allows your staff to mirror your practice in the most favorable light. 

When the team knows what you were thinking about on each case and they know what is expected, they gain an understanding that is reflective of the quality of care you provide. 

You will have less stress.

Yes, this is one of the biggest and probably most obvious benefits.  However, incomplete charts wreak havoc on you in more ways than one. 

There seems to be a universal conundrum that Periodontists face when it comes to completing chart notes.  You become enslaved to endless nights and weekends trying to keep up when your records aren’t contemporaneous. 

There are a few other related points to consider. 

When you, the doctor, personally document each case from scratch you not only create a redundant and laborious time vacuum, you also prevent your team from being able to easily contribute to the process. 

If your staff doesn’t know the case, and the referring practice calls to ask questions in search of the correspondence, everyone is left feeling handicapped and forced to wait on you for the answers.  A quick read of well-written notes could have eliminated wasted time and energy.  Trying to recoup a clumsy record system over the phone sends the wrong message.

Not only does this type of dependency create chaos and extra work for you and your staff, but it also leaves everyone feeling frustrated and left out.  In the meantime, your staff's hands are tied, they can’t help answering questions if they don’t feel confident in their role. 

The worst part is, when the referring practice doesn’t feel involved in the care, the message sent is that you care more about yourself than you do about the welfare of the patient.

What exactly “defines” effective record keeping?

Consistency is the key and it needs to include the entire team, not just the doctor.

Instead of letting everyone go rogue in their writing style, educate your team in a simple and structured way so they follow the same protocol. 

Instead of sitting down to freely draft an open-ended storyboard, effective record keeping should be a matter of simply checking and completing the process from a predefined list of criteria.  

Creating easy to follow steps eliminates inconsistency and or forgetfulness. Even if some of the team members only come equipped with a very basic level of understanding a well-defined protocol allows even those individuals to have the knowledge of what needs to happen in order to be successful. 

Have a reliable system in place that will automate the process for you. 

Why reinvent the wheel on each case?  PANDA Perio addresses this need perfectly and will allow you the flexibility to be as detailed as you need while eliminating the redundancy so you can get on to bigger and better things. 

PANDA Perio provides the structure for your team by giving them simple to use steps requiring little to no typing.  PANDA Perio provides an interactive data collection process to guide your staff into creating complete and robust chart notes, eliminating type-o's and the need to guess what data to enter.  Even the least skilled person in the practice can become a superstar when using this proven, consistent and easy to follow method of data collection.