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Duane Tinker returns to the podcast today to join Andrew and Michelle for a discussion about patient records and charts in the dental field. Listeners may remember that Duane is a former law enforcement officer who is currently the CEO of Dental Compliance Specialists, a company that works with dental practices across the United States to ensure staff are well-trained in infection control and are working with the best and safest equipment. Known as “The Tooth Cop”, courtesy of his previous line of work in Texas law enforcement, he’s also the host of the ‘Talking with the Tooth Cop’ podcast. Today he discusses the importance of charting and why auditing is necessary.
In this episode, Duane discusses the importance of documentation in patient records, how cases where notes are inconclusive can pose legal and billing issues, what is needed in a document when signing electronically, and why shorthand should be kept to a minimum for easy communication. He goes on to review the pros and cons of using templates, the importance of reviewing and tweaking them whenever using them, and finishes off with a discussion about the auditing process, including how it is done, and why it should be done on a regular basis.
Interview starts: 12:36
– Duane Tinker talks about living the dream in his RV
– The challenges that come with the nomad life
– The importance of documentation in patient records
– What to include when signing electronically
– Should shorthand be allowed?
– The pros and cons of using templates
– The key components of a template note
– Handling the conversation when correction in notes is needed
– The American Dental Hygiene Association standard
– Why Perio charting?
– Why do dentists need to train their assistants on documentation procedures?
– Documenting x-rays and intraoral pictures
– What is the auditing process?
“One of the most beautiful things about being a business owner is being able to have a vision and create that vision and then execute.”
“The number one most common problem is no clinical note.”
“Every time that you see a patient, there’s a story that unfolds there and you know, it’s your job, whether you’re the dental assistant, the dentist, or the hygienist to tell their story.”
“Communication is key and in an effort to not be misunderstood, let’s just use plain English.”
“Your whole goal with your note is to paint a picture.”
“It takes a real talented person to be able to point out the positives and focus on the positives because you know, you have to give a little reward, give a little sugar, with medicine.”
“The only perfect template is the one that you’ve reviewed and tweaked, modified to suit your needs.”
“Your dentistry is only as good as your documentation. If you don’t care enough to do that half the job, then why bother to show up and do the other half?”
“It’s important to document objective information with things that you can see, feel, touch…observe with your five senses, okay.”