Documentation is a very important piece of the dental hygiene process of care. Chart notes are considered legal documents and, according to the American Dental Association, are “critical in the event of a malpractice insurance claim.”1 The notes keep track of the procedures, treatments, recommendations, and findings from previous dental visits.
The documentation also reminds dental hygiene professionals how the patient is doing in regard to maintaining or improving oral health status. Progress notes tell the next clinician about what’s going on with the patient and what the next steps are regarding care.
What Needs to be Included in Dental Hygiene Progress Notes?
Everyone has their own way of writing notes. Some are short and to the point, while others are very detailed and, at times, lengthy. Whatever your preference may be, a few items of important information should be available on a patient’s progress notes.
A dental hygiene note should include:
Medical history. Review and update it, noting any changes (medications, allergies, surgeries, medical conditions, etc.). If a patient reports no changes in their medical history, state, “Patient reports no changes” in your notes.
Intraoral/extraoral cancer exam. Describe any findings inside or outside the mouth (color, type of finding, size [using a probe, measure the finding; is it raised?], etc.).
Calculus and biofilm deposits. Note the amount (light, moderate, heavy), supragingival and/or subgingival, generalized or localized, location of deposits (interproximal, facially, at the gingival margin, etc.).
Bleeding and inflammation. Note the amount (light, moderate, heavy) and whether it’s generalized or localized.
Treatment rendered during current appointment. Note radiographs, periodontal assessment (any changes in probe depths, recession, etc.?), sealants, scaling (hand scaled and/or ultrasonic instrumentation), doctor exam (any restorative treatment recommended?), and treatment rendered (prophy, periodontal maintenance, non-surgical periodontal therapy/SRP, gingivitis treatment, fluoride treatment, etc.).
Periodontal status (stage and grade). Does the patient present with recession or furcation involvement?
Other clinical findings. Observations such as attrition, abfractions, chipped teeth, failing restorations, etc., should also be noted.
Patient concerns. Report any chief complaints or concerns stated by the patient. For example, concerns of halitosis, pain, esthetic concerns, tooth sensitivity, etc. Be sure to write this in the patient’s words.
Oral health instruction and recommendations. Did you give the patient OHI, for example, for an electric toothbrush, interdental cleaning aids, a different home-care technique, dental treatment, more frequent recall, etc.
Hygiene dental exam. Any notes during the dental exam (diagnosed dental caries, restorative work that was recommended, or referrals).
Next appointment. Anything that the patient would be due for during the next visit (radiographs, sealants, etc.). Does something in the oral condition need to be re-evaluated at the next visit? What is the patient’s recall frequency (three, four, or six months)?
Your full signature with credentials. You are signing a legal document!
More Questions Than Answers?
This crucial information allows for transparency and avoids miscommunication (or confusion) for anyone else reading it. I have seen patient notes with minimal details that created more questions than answers.
If multiple hygienists are in the office, sit down and discuss what everyone sees as important items to incorporate in patient notes. This will allow some similarities with the notes for the practice. If you write progress notes digitally, many dental software programs have the function to create patient note templates, options to click on, or drop-down options.
I am teaching my first-year students right now about the importance of documentation. My goal is to start having them connect what they are doing chairside into patient notes. I want them to have light bulbs going off in their heads. If a patient presents with something, does that cause a treatment to be recommended? Instead of just laundry listing what they did during that specific clinic session, I like to see statements on why their patient is a high risk of caries or why they are being classified with periodontitis stage II.
Just like each patient, progress notes will be a little different for each clinician. Some notes will be shorter or longer than others. When I have patients who are periodontally involved, I might have a few more things to say, such as a change in probe depths. Or, if I have a new patient, I know I will need to incorporate more information about their dental history.
Knowing what you need to incorporate in a thorough dental progress note will help you remain organized and flow smoothly through the entire appointment.
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- What is the Dental Record? (n.d.). American Dental Association. Retrieved from https://success.ada.org/en/regulatory-legal/dental-records