October 2, 2010

How to Write Code and Charting Notes with Carestream/Kodak PracticeWorks

I have been using PracticeWorks in my practice since the 1990’s and am continually amazed at how many dentists have it, but do not use it for charting their dental procedures.  Sure, there are other dental software packages used throughout the field of dentistry, but few have the ability to chart dental notes like PracticeWorks (PW).

Over the years I have written note code to make charting in PW easy, fast and medically-legally sound.  The notes are written in the logical order that the procedures are done. Notes can be modified and edited on the fly, and can be filled out by your assistant (even though I do not let mine).  Below will be listed templates and descriptions of how to write and edit dental notes, and how to link different procedures, prescriptions and forms to the patient’s chart. For those of you who have had PW for years and never used this powerful charting function, follow the instructions and let me make your life a whole lot easier.

Building your Dental Notes:  Some doctor’s notes that I have seen either mailed to the office or carried in by the patient that were written on PW have been a series of little snippets that were added in a row to constitute various exams and observations seen/performed throughout the patient’s dental visit.  For instance, there will be an oral cancer screening note separate from the fluoride note, and so on and I find this very disjointed.  Writing these type of notes in a busy or lazy practice can be easily overlooked or not added even though they were performed.  Remember, medically-legally speaking in the court of law, it is what the patient says happened versus what you have written down that counts.  I find it best to combine snippet notes in an all-inclusive note, such as, “Exam/X-ray” note.  This note follows the SOAP format and can make your exams look good on paper no matter what you find in the patient’s mouth.

Other notes can be called Filling(s), Extraction(s), Denture(s), Crown/Bridge, TMD/Clicking/Popping, Myofacial Pain, Prophy, S+RP, Immediate Implant, Implant(s), CT Graft, Referral, Endo, Apico/RetroFill, and so on as you like.

Now here comes the beautiful part about writing the notes, they are all made up of variables, and these variables can be used in every note as you need them.  In other words, every time you write a note you do not have to re-invent the wheel.  If you wrote a good local anesthetic variable or series of variables intermixed with bridging text, you can put it in all your notes in which you would even remotely use local anesthetics. Every note can have a prompt button to say that you “Reviewed Health History”, “Verbal Informed Consent given”, “treatment tolerated well”, “oral hygiene instructions given”, and of course “Next Visit:”.  I would hope that somewhere along the line you learned to NEVER let a patient leave your office without it being noted somewhere what the next visit will be.  Even if it was just “Next Visit: Re-eval”.  Medically-legally if someone came to your office for even a small problem and a year later develops cancer, if you didn’t have some follow-up appointment scheduled or written down what’s next, you may be in for the fight of your life!

These notes will keep you out of trouble.  They will keep you on track, and are fast and easy to fill out.  Many times I can have even a large note filled out before the dental assistant can clean up the patient and dismiss them from the room.  The notes are written in outline form that leaves no stone unturned.  All the words are spelled out so you are not left guessing what someone did or meant years later.  When I am doing a Detailed/Complicated Exam for myofacial pain, for example, I simply put up the note on the computer and follow the logical pattern of variables so I do not miss a thing.  You can modify your note in any way by simply placing the curser where you want to make changes, and edit the note, complete with spell check.

I hope you find these note templates, examples and variables useful.  They have been written and re-written over many years and are still a work in progress.  All comments are welcome.