Thursday 16 September 2021


 


I have recently had several conversations with dentists worried about their clinical notes some of them are staying many hours after surgery to write their notes, causing mental stress and anguish not to mention the damage it causes to family relationships and physical heath.

Your notes need to be CLEAR
CLEAR NOTES
C = Contemporaneous
L = Legible
E =Easy to understand
A = Accurate
R = Respectful

Contemporaneous,
This means occurring at the same time. For many young dentists this they find the most difficult because of time pressures. It is essential that your notes are written at the same time as the patient’s appointment, not at the end of the day. For an unbreakable habit that your next patient is not brought in until you have fully written the notes.
Using templates can be useful and they must be edited for each patient
Your nurse is also vital. Spend time with them designing your consultations, what you want them to writ, as you are speaking with the patient.
Don’t rely on your memory. If it is easier to use an ipad or pen and paper to record notes, as you are sitting along side your patient, please do. Never turn you back to a patient or sit at a computer terminal behind them, our research show that your patient will divulge less information when you do.
If you feel you don’t have enough time in your consultations do some self-reflection, get a mentor / coach to come and spend time with you in the surgery, together come up with new solutions and never compromise your standards.

Legible
This is easier now most of us use computers. Remember to write in English if you are practicing in UK and not an overseas native tongue.

Easy to understand,
At some point someone else may read your notes and they need to make sense.
Whilst you don’t need to use full sentences and paragraphs, they do need to make sense.
If you are using abbreviations, make sure they are commonly used, and you have a glossary of meanings to refer to.

Accurate.
It goes without saying that your notes need to be a true reflection of a clinical situation, or conversation. Whilst it is not encouraged for clinicians to record consultations, remember your patients probably are.
A picture paints a thousand words, so although hey use a lot of computer memory, photos are a really useful adjunct to your notes.
Spending time training your nurse, so you have shared understanding about what should be recorded is essential. Your nurse can be recording conversations in the notes, making notes of exact phases used.

Respectful
Because someone else may read your notes in the future, please use respectful language. Your patient, may have used foul language, been a bully, or a racist record that accurately and never use defamatory language in your notes, keep them fact based free of emotive opinion or insult.
If you would like to discuss anything about CLEAR note taking, you can book a FREE CALL FRIDAY or TASTER coaching session at www.theinstituteofdentalbusiness.co.uk