Chart note:Post-op call, specialist/other DDS conversation

[waynelyn]

How are people making chart notes for post-op calls for patients as well as conversations with other DDS/specialists/MDs regarding patient care?

Typically in a paper chart I'd just write in the next entry after a procedure. Is there a place to place these important notes that are permanent part of the patient record? I was thinking of adding a custom code for post-op calls and one for the other DDS/Specialist/MD and posting the procedure. The problem with that is that there will be those entries in the patient ledger.

Suggestions?

[jrpappy]

I use the commlog for all conversations with patients, specialists, etc. It's great that they show up in the chart notes (as well as the account page) because they flow with the chronology of tx and referrals. I make sure that I tag them as being "clinical", and have the front desk use different and appropriate labels for their communications with patients, insurance companies, etc.

[waynelyn]

That's great idea. My biggest concern though is that they can be deleted and altered, unless any change is still registered as with the procedure notes. Is there a security feature to not allow deleting the commlogg entry say after 1 day? How do you tag them as "clinical"? I don't seem to have the option available to me. Thanks.

[jclaydds]

I normally use a "clinical note" rather than the Comm Log. If memory serves me right, the dummy codes for a clinical note (zclin), tooth note (ztoth) and appointment note (zAppt) was already in the Procedure Code List. If they weren't, I guess I added them. To make it easier to enter these notes, I have a "Notes" category in my Procedure Button Section and then these 3 note types are options. It just takes a click or two to enter them into the chart and then I click on the note and make the appropriate notes such as conversations with a specialist, post op, etc.

Jeff

[Pruce Dental]

I chart mine the same as Jeff suggested but when using a dummy code do not set the dummy code as "complete". Instead set it as "existing current provider" so it doesn't show up in the account ledger.

[Hersheydmd]

I do the same thing, except I set my communications with other doctors/specialists to "Existing Other Provider". I like it because it shows up in a different color (green) from my regular progress notes.