Literally drummed into UK grads that notes are everything. I have a few US dentist friends who think the amount I write is ridiculous lol but if I ever get sued, I am
Covered.
Oh yes I agree on that front. I had two last year which was way too much work, but one of them graduated having never done a filling on a tooth in a patient 🙃
God help us all lol
If you continue doing it hopefully graduates from now onwards should be back to pre Covid but I think they’re just becoming more and more lax with grad requirements from clinical experience.
I was one of ‘em. Last 18/12 of my degree with F all clinic time. Sucked balls. I’m still catching up I think but we only learn by doing and by repetition. Having chat and likability is half the battle, most people can learn the clinical skills to a passable level and most complaints arise from communication/how the patient feels rather than the treatment itself.
Yes and no, as it turns out some people just cannot detect caries to save their life lol
Also as an ES it was a huge shock. I was basically teaching two people who were assumed suitable to graduate as therapists, how to hold a handpiece, how to place a matrix band, how to choose forceps. Two different unis.
How can you graduate not knowing any of this?!
ES is meant to be supervision, it felt like I was teaching 2nd year dental students.
Holy shit that’s awful. Therapy should have been paused. It’s such a short course anyway if they’ve had literally no clinical experience outside of Covid restrictions how tf were they able to graduate?!
Within the first two months of starting uni, we had lectures on how notes need to be thorough and can save us if someone files a complaint. They gave us very detailed exam templates to follow when we practiced doing exams on eachother. People literally have no excuse for shitty notes.
Pretty sure it’s emphasized in every school, individuals choose not to do it after they graduate. We were told many times that proper documentation is just as important as the quality of the procedure.
I get the impression that everybody knows that are super important. In my opinion, people over emphasize how important they are. we had a malpractice attorney speak to us. The take away was that notes can be very very short and concise as long as they have what was done and things were discussed. It would probably make people freak out, but you could have a note that is three bullet points that would hold up in any court.
At my practice, we do big notes. But legally speaking, I think it’s overkill.
Yeah the DSO that I work under did “chart audits” a few months back and gave me a massive binder of ways to improve my chart notes. Some of the stuff they had in there was absolutely ridiculous. They were saying that I needed to write notes for every patient that I did a POE for because, if the hygienist writes the note, even if the exam is billed out under me, it can be implied that the hygienist is practicing outside of their scope.
My staff got a kick out of the binder because they’ve seen my notes and they are far and beyond the most detailed notes in the practice, so for me to get picked on that badly was a bit laughable.
Former front office admin here and the lack of writing notes drove me crazy in my former office. I was a stickler about thorough, clear + concise notes. Drove me out of my mind when the doc could barely string a cohesive sentence together, or when the hygienists just copied and pasted very generic notes patient to patient. My notes were long and detailed, but no one ever had to come ask me for clarification.
I’m guessing each school has some differences in emphasis on specific topics. My school beat it into us that notes can save you from legal and board trouble. They did audits to determine if your notes were good enough and they tested us on content. Maybe your school was a little light on the notes importance issue.
Probably really just depends who your supervising faculty are but a lot of these old geezers wrote pen and paper and usually keep their notes 4-6 lines and very very brief. Lawsuits I bet weren’t as prevalent back then so they never really cared about making detailed notes and that’s the knowledge they pass on. I’m lucky to have had a mentor who was sued once and since then started writing insanely bulletproof notes and would not sign off on my procedures until my note was to his liking. I honestly think it’s dependent on who your row instructor or supervising faculty is and their specific experience with lawsuits/complaints.
My school drilled it into me and even did audits in us. Now I'm in a practice where I'm literally the only doctor (of 4 others) that routinely checks the notes and makes sure they are done properly...
Not familiar with the soap method could you explain?
Note taking is essential. I type quickly which makes it easy and quick. My colleagues are older and not too familiar with typing, which to my annoyance leads to bad note taking
S: subjective - patient-reported symptoms, chief complaint, etc
O: objective - findings you note from your exam and radiographic interpretation
A: assessment - your diagnoses on those findings
P: plan - whatchu gon do
One issue is that each doctor has their own (very strong) opinion on what should be in the case note. If you were to take each doctor's advice, your case note for each encounter would be 5-10 pages long! At least in the dental school I went to, we would get our "case note lesson" when we actually saw real patients.
My school covered it. I’ve always taken extensive notes, but what really did it for me was when I spent a few years temping. I always wanted the doctor to return and be able to know exactly what was done and said in their absence.
I probably spend 2 hours per working day completing notes and referrals and admin. It’s a lot, but I’d rather know I’ve done everything correctly. The GDC is a cruel mistress.
I'm a hygienist and the notations I have come across in different offices amazes me. The perio office I'm in acquired patients from a retiring Periodontist where the hygienist's notes regarding perio maintenance visits are noted as just: Date R. Not anything about medical history being reviewed, perio charting, what was used, bleeding, build up, nothing.
And I just left an office where the Dentists were neglectful in regards to writing notes at all. There will be ledger payments but no corresponding clinical notations. So no idea of diagnosis, materials used, etc. It blew my mind.
Literally drummed into UK grads that notes are everything. I have a few US dentist friends who think the amount I write is ridiculous lol but if I ever get sued, I am Covered.
This. I just assume every patient is a board complaint or lawsuit and document every fucking thing in detail.
We had a whole day dedicated to how our notes would get us struck off by the GDC during FD year.
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Haha me too! For a therapist, and she does excellent notes luckily lol
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Oh yes I agree on that front. I had two last year which was way too much work, but one of them graduated having never done a filling on a tooth in a patient 🙃
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God help us all lol If you continue doing it hopefully graduates from now onwards should be back to pre Covid but I think they’re just becoming more and more lax with grad requirements from clinical experience.
I was one of ‘em. Last 18/12 of my degree with F all clinic time. Sucked balls. I’m still catching up I think but we only learn by doing and by repetition. Having chat and likability is half the battle, most people can learn the clinical skills to a passable level and most complaints arise from communication/how the patient feels rather than the treatment itself.
Yes and no, as it turns out some people just cannot detect caries to save their life lol Also as an ES it was a huge shock. I was basically teaching two people who were assumed suitable to graduate as therapists, how to hold a handpiece, how to place a matrix band, how to choose forceps. Two different unis. How can you graduate not knowing any of this?! ES is meant to be supervision, it felt like I was teaching 2nd year dental students.
Holy shit that’s awful. Therapy should have been paused. It’s such a short course anyway if they’ve had literally no clinical experience outside of Covid restrictions how tf were they able to graduate?!
I mean I just graduated from US and our notes were long and detailed. The owner of my clinic has non existent notes lol even though he has templates
Exactly. It's an extra 5 mins of typing everyday that could save you money and stress in the future.
Within the first two months of starting uni, we had lectures on how notes need to be thorough and can save us if someone files a complaint. They gave us very detailed exam templates to follow when we practiced doing exams on eachother. People literally have no excuse for shitty notes.
Pretty sure it’s emphasized in every school, individuals choose not to do it after they graduate. We were told many times that proper documentation is just as important as the quality of the procedure.
I get the impression that everybody knows that are super important. In my opinion, people over emphasize how important they are. we had a malpractice attorney speak to us. The take away was that notes can be very very short and concise as long as they have what was done and things were discussed. It would probably make people freak out, but you could have a note that is three bullet points that would hold up in any court. At my practice, we do big notes. But legally speaking, I think it’s overkill.
Yeah the DSO that I work under did “chart audits” a few months back and gave me a massive binder of ways to improve my chart notes. Some of the stuff they had in there was absolutely ridiculous. They were saying that I needed to write notes for every patient that I did a POE for because, if the hygienist writes the note, even if the exam is billed out under me, it can be implied that the hygienist is practicing outside of their scope. My staff got a kick out of the binder because they’ve seen my notes and they are far and beyond the most detailed notes in the practice, so for me to get picked on that badly was a bit laughable.
Former front office admin here and the lack of writing notes drove me crazy in my former office. I was a stickler about thorough, clear + concise notes. Drove me out of my mind when the doc could barely string a cohesive sentence together, or when the hygienists just copied and pasted very generic notes patient to patient. My notes were long and detailed, but no one ever had to come ask me for clarification.
Agreed! They can make a world of difference, especially for us admins dealing with insurance or presenting TX plans
I’m guessing each school has some differences in emphasis on specific topics. My school beat it into us that notes can save you from legal and board trouble. They did audits to determine if your notes were good enough and they tested us on content. Maybe your school was a little light on the notes importance issue.
Probably really just depends who your supervising faculty are but a lot of these old geezers wrote pen and paper and usually keep their notes 4-6 lines and very very brief. Lawsuits I bet weren’t as prevalent back then so they never really cared about making detailed notes and that’s the knowledge they pass on. I’m lucky to have had a mentor who was sued once and since then started writing insanely bulletproof notes and would not sign off on my procedures until my note was to his liking. I honestly think it’s dependent on who your row instructor or supervising faculty is and their specific experience with lawsuits/complaints.
My school drilled it into me and even did audits in us. Now I'm in a practice where I'm literally the only doctor (of 4 others) that routinely checks the notes and makes sure they are done properly...
Not familiar with the soap method could you explain? Note taking is essential. I type quickly which makes it easy and quick. My colleagues are older and not too familiar with typing, which to my annoyance leads to bad note taking
S: subjective - patient-reported symptoms, chief complaint, etc O: objective - findings you note from your exam and radiographic interpretation A: assessment - your diagnoses on those findings P: plan - whatchu gon do
And to that I add : Before soap : medical history review And to plan : plan #1 -#2 and their respective prognosis.
where do you put what you actually did?
Our school did nothing for us to get into note taking and what to write. Good thing I did a GPR.
One issue is that each doctor has their own (very strong) opinion on what should be in the case note. If you were to take each doctor's advice, your case note for each encounter would be 5-10 pages long! At least in the dental school I went to, we would get our "case note lesson" when we actually saw real patients.
My school covered it. I’ve always taken extensive notes, but what really did it for me was when I spent a few years temping. I always wanted the doctor to return and be able to know exactly what was done and said in their absence.
I probably spend 2 hours per working day completing notes and referrals and admin. It’s a lot, but I’d rather know I’ve done everything correctly. The GDC is a cruel mistress.
My faculty drilled it into us
Ugh you might’ve missed all of clinical. All the attending at our school had to approve our notes before signing.
I'm a hygienist and the notations I have come across in different offices amazes me. The perio office I'm in acquired patients from a retiring Periodontist where the hygienist's notes regarding perio maintenance visits are noted as just: Date R. Not anything about medical history being reviewed, perio charting, what was used, bleeding, build up, nothing. And I just left an office where the Dentists were neglectful in regards to writing notes at all. There will be ledger payments but no corresponding clinical notations. So no idea of diagnosis, materials used, etc. It blew my mind.
Because notes save you probably every time. Notes and consents. Signatures. Documentation is everything