Progress Notes question

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openwide
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Joined: Mon Feb 14, 2011 6:16 am

Progress Notes question

Post by openwide » Fri Jul 22, 2011 12:34 pm

I am about to start putting all my procedure notes in OD. Trying to come up with strategy? How do you guys deal with multiple procedures or teeth in 1 appt?

For example:
1. I understand if i do 3 fillings in one arch I can group note all three but what if you do 2 separate arches? Do you put individual anesthesia for each arch? On paper I would not chart separately.
2. New patient comes in with toothache. You do exam, x-rays, filling, extraction in that 1 visit. Do you group note everything as I would in paper notes? Do you break it down by procedure? How do you note anesthesia? Do you group note the anesthesia and then individual notes for different procedures?
3. Hygiene - x-rays, exam, prophy, flouride. Do you group note everything? Does hygiene note there part and doc notes exam seperately?

How do you guys do your notes?

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drtech
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Re: Progress Notes question

Post by drtech » Fri Jul 22, 2011 5:33 pm

I just pick one procedure and put the notes in that one. the rest of the items on the same day all fall together with that note. No grouping or anything needed.
David Fuchs
Dentist - Springfield, MO
Smile Dental http://www.887-smile.com

teethdood
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Re: Progress Notes question

Post by teethdood » Fri Jul 22, 2011 5:34 pm

I just attach all performed procedures into the appointment and set complete. Then switch over to progress notes, select the last black item to appear, and do autonotes there. This is how I would write the chart on paper, so the digital notes get the same treatment.
Edit added: For certain procedures like exams (Comprehensive, Periodic, Limited etc) they get their own notes section partially filled (you can set this up by going to Procedure Codes) as a reminder to chart MH DH EOE & IOE stuff.

<gripe on>Let's say I treatment plan #4 RCT/BU/CC. The proc codes are listed in "alphabetical order" based on the CDT code, so the BU/CC would appear first, then the RCT last. The estimated insurance payment is calculated for the BU/CC and by the time it reaches the RCT, it says "maxed out". It should calculate for the RCT first. I can easily prioritize the RCT first then the BU/CC in small treatment plans. However, if I have a huge treatment plan, prioritizing every single tooth like this can be seriously tedious. This same thing applies to writing notes in the chart: why would I do a BU/CC first before doing an RCT as the progress notes show<gripe off>
Philip H. Doan, DDS
http://www.kaweahdental.com/

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Hersheydmd
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Re: Progress Notes question

Post by Hersheydmd » Sat Jul 23, 2011 11:54 am

Each procedure that has a billing code has to be entered individually in the progress notes.
I complete a note for each procedure and sign or initial it. It takes a drop longer but makes it much clearer to follow. I use autonotes as much as possible.
If I work on two adjacent teeth and give anesthesia I enter the anesthesia on the first note, but each tooth gets it's own note regarding the filling itself.
If the hygienest takes radiographs and does a prophy, there will be a procedure note for the prophy that she will have to sign and several procedure notes for the x-rays. Let's say 4BW & 4 PA's were taken. There will be 8 procedure notes entered, one for each procedure code. On the first radiograph note she will type the x-rays taken ("4BW & 4PA"), and she will only sign that first x-ray note, rather than all 8.

I gave up using group notes, but I can see them working for some users.

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Robert M Hersh DMD, FAGD
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Brooklyn, NY 11234
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babysilvertooth
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Re: Progress Notes question

Post by babysilvertooth » Tue Jul 26, 2011 4:06 am

gripe on>Let's say I treatment plan #4 RCT/BU/CC. The proc codes are listed in "alphabetical order" based on the CDT code, so the BU/CC would appear first, then the RCT last. The estimated insurance payment is calculated for the BU/CC and by the time it reaches the RCT, it says "maxed out". It should calculate for the RCT first. I can easily prioritize the RCT first then the BU/CC in small treatment plans. However, if I have a huge treatment plan, prioritizing every single tooth like this can be seriously tedious. This same thing applies to writing notes in the chart: why would I do a BU/CC first before doing an RCT as the progress notes show<gripe off>

I have this gripe too, and I feel it is a pretty big one, considering you would have to set a priority for RCT, P+C, Crown as seperate lines rather than grouped together.....

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Hersheydmd
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Re: Progress Notes question

Post by Hersheydmd » Wed Jul 27, 2011 2:24 am

Prioritizing the procedures is actually a VERY GOOD IDEA as it will be easier to see your planned work flow. And it will show in the progress notes in the order you want.
It will also force the procedures to be listed on the insurance pre-treat estimate in the order you want.
You can't group the procedures together into one procedure because each one has to have it's own line on the insurance claim.
Robert M Hersh DMD, FAGD
Univ. of Penn 1982
Brooklyn, NY 11234
https://www.facebook.com/pages/Robert-M ... 1471599429

openwide
Posts: 56
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Re: Progress Notes question

Post by openwide » Mon Aug 01, 2011 7:06 am

Thanks for all the info guys. Seems like most of you don't use Group Notes.

Whats the downside to using Group Notes?

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