In some ways it is surprising that something so basic to dental practice is so often overlooked. In other ways, the negligent attitude of dental practices concerning records is understandable. Record-keeping can be tedious and boring.

Boring or not, record-keeping and its companion action, reimbursement, are two major facets in the dental practice "jewel" that keep us in business. In fact, everything that we do can be distilled into some form of data collection and record-keeping, and everything we earn can be listed under the heading of reimbursement.

Is there any way to make record-keeping more efficient and less of a chore? Is there a way to use our record system to make reimbursement less problematic? Can record-keeping be used as a practice-builder?

The answer to all three questions is yes.

This afternoon, take the time to look over a typical patient chart on your shelf. Can you find the diagnosis and treatment plan? Look at the progress notes. Can you see what was accomplished at the patient's previous visit? What about the patient's next appointment -- what will you be doing, how much time will it take, and what fee will be collected? If you cannot find the answers to these questions, your charting system needs to be brushed up and set straight.

It isn't as difficult as you might think.

First: Accurate record-keeping begins with a documented diagnosis, which begins with a base record. Dedicate yourself to obtaining such a record for all patients, including existing conditions, pathology, and recommended treatment notations. This should be done at the patient's first appointment. If you have not been doing this consistently, you can begin by performing complete data collection during any "new patient" visit, and expand by providing this at all recall appointments until all of your patients have been caught up. To apply the previously mentioned criteria of efficiency, reimbursement ease, and practice-building, think of this: A detailed diagnosis makes all subsequent visits go smoothly. You do not have to keep rethinking the case. Reimbursement, particularly when working with a patient's insurance, is easier when all the facts are in one place. The claim form can be filled out quickly and correctly the first time. As for practice-building, when patients see and hear the detailed examination they are receiving, their trust levels increase. They are more inclined to accept our recommendations and refer their friends.

Second: Design a treatment plan on a worksheet or "treatment schedule" that provides information concerning all treatment visits needed by the patient to complete their care. The plan should include details of each appointment, length of time required, fees to collect, and special concerns. The treatment schedule should be so complete that any person in the office can pick up the patient's record and understand what needs to be done. Under our three criteria: Efficiency is enhanced because all dental team members know what will be done during the patient's visit. Room set-ups, lab case retrieval, and needed materials can be readied in advance of the patient's arrival. Reimbursement is improved because money to be collected or claims to be sent are listed on the treatment schedule. Patients do not neglect to make payments because each team member knows the payment amount due. Practice-building is a natural by-product. Many patients have received haphazard care from disorganized offices that never seemed to know what was expected. Your office is different and patients will put out the word.

Third: Keep your progress notes in good shape. Be sure that you are writing down everything that happens with the patient. This includes prescriptions and phone calls. Progress notes must be handwritten in ink, typed, or generated by a computer. Informed consent must be documented or included as a separate form for the procedure being accomplished. All entries should be signed or initialed by the person recording the information. Remember that the dentist is responsible for reviewing all data and must leave his/her initials as well. If recorded data has to be altered later due to an error, a single line should be drawn through the incorrect information (so that the information can still be read), and the correction entered. The correction should contain the new information and the reason for the change. It should be dated and initialed. "White-Out" or erasures must never be used. If your progress notes are electronic, the programs must be safeguarded so that alterations or loss of data does not occur. To apply our criteria: Efficiency is enhanced because there is no need for data searches for missing information; reimbursement is easier because questions regarding what treatment was performed and at what cost are eliminated; and practice-building occurs when patients find their bills and insurance payments make sense.

When faced with problems in our offices, we often look to find some new, different, exotic, or glamourous solution. We think that if we just mastered that new technique or purchased that new equipment we would find the answer to our difficulties. While mastering new techniques can bring better treatment for our patients and new equipment can make our work easier, often the simple action of improving what we are already doing can make a big difference in how our offices operate. It doesn't make sense to spend money on a new piece of equipment if you cannot figure out from your patient's chart what you are going to do today. What good is mastering a new technique if you cannot implement it into a well thought-out treatment plan? In other words, what good is a brand-new paint job for the car if the engine won't run?

Spend some time improving your existing record-keeping and reimbursement systems. If you do not like your charting forms, don't necessarily change all of them right away. Make one small change this month that you think might make a difference. Find a new form for data collection or informed consent. Make a commitment to formulating and documenting a complete treatment plan for your next new patient and stick to it. You will be amazed at what one small change each month can accomplish by the end of the year.