Dental clinical notes: 3 reasons they are crucial to your success

As a dentist, your practice’s overall success can be defined by even the smallest of tasks: your dental clinical notes. It might seem like a small detail to pay attention to when you are with a patient or creating an insurance claim. 

But accurately completed and detailed dental clinical notes can come in handy in more than one circumstance - and are every bit as important as the dental care you provide your patients.

You’re probably wondering, “I try to always be detailed in my clinical notes, but why exactly is it so crucial that they are detailed and accurate?”

Dental ClaimSupport has spent years working with dental teams - some who have faced challenges that could have been avoided had their clinical notes been higher quality. When we handle claims for teams, we see denials happen due to a lack of clinical notation. And claim denials can lead to delays in payment from insurance companies. Don’t worry, we’ll get more into that later in the article. 

But other issues can arise from poor dental clinical notes as well. In this article, we’ll share 3 reasons dental clinical notes are crucial to your financial, legal, and overall success at the dental practice.

1. Dental clinical notes improve your rate of claim reimbursement 

As promised, let’s get into why clinical notes are crucial for insurance claim reimbursement. 

When you submit an insurance claim, you must provide proof that the treatment you performed was necessary for the health of the dental patient. This proof can come in the form of: 

• X-rays
  • Periapical (PA)
  • Bitewing X-rays (BW’s)
  • Panoramic (Pano) 
  • Full Mouth X-ray (FMX)
• Intraoral photos (IOC)
• Clinical Charting 
• And of course, clinical notes. 

Your clinical notes specifically, will include the following information: 

• The patient’s name and contact details
• Up-to-date medical history
• Prior and current treatment information
• Any missed appointments or unscheduled treatment - when or if you have offered treatment to a patient and they have declined
• Prescriptions, medications (with details of amount, dosages, and frequency) dispensed or injected during the appointment.  

When it comes to claim reimbursement, the more details on your clinical notes, the better. Dental insurance companies are always searching for new ways to delay claim reimbursement. So it’s always best to almost over-explain yourself on all of your documentation, specifically your clinical notes. 

Remain compliant when completing your clinical notes

Not only do you need to add as much detail as possible in your clinical notes, but you also need to document information properly.

For example, did you know that CDT code D0120 Periodic Oral Evaluation - established patient, was revised in CDT 2022 updates?  

The updated nomenclature now reads as: 

“An evaluation performed on a patient of record to determine any changes in the patient’s dental and medical health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation, periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures. The findings are discussed with the patient.”

In this case, you will report additional diagnostic procedures separately. 

This means that if the findings are not discussed with the patient - and/or are not listed in the clinical notes, you could be audited and the insurance company may request all payments made for that procedure code to be returned. This is because your clinical notes do NOT support your code.  

That could present a big financial issue. 

When you know how to properly document procedure codes in your clinical notes, you give insurance companies fewer reasons to deny your insurance claims. Avoiding denials can lead to quicker claims income, which typically accounts for about 50% of overall practice revenue. 

You don’t want to miss out on that money just because you inaccurately documented information in your clinical notes. 

2. Dental clinical notes can be used to defend yourself legally

Dental clinical notes can come in really handy when you face any kind of legal issues at your dental practice. 

In the dental or medical field, there are always going to be risk management issues. You’re dealing with people’s health as your way to make an income - legal risks are part of it, unfortunately. But these legal risks can be avoided. Dental clinical notes can act as evidence that a procedure or treatment you performed was necessary, and done correctly. 

Even small details in your clinical notes can legally make a difference

Here’s an example: 

A patient comes in, you work hard taking every step to make them a beautiful and great fitting denture. You do a preliminary impression, custom tray final impression, bite registration with a facebow and mount it perfectly on the articulator, then a wax try-in with the teeth and the size, shape, midline, color is spot on and the patient then returns for the delivery of the denture.  

You are both happy with the results, but she was always in a big hurry leaving after her appointments and did not pay. The administrative team did not collect the payment or maybe you didn’t have a financial agreement and then… Surprise! 

When you attempted to collect for her unpaid denture, the patient is all of the sudden unhappy with the denture, stating she did not like the color, the shape, the color of your beautiful denture that you spent hours (and money!) on.

You go back to your clinical notes to see if the patient was happy at the wax try-in and delivery date, only to discover your clinical documentation is lacking. The supportive documentation at the wax try-in doesn’t mention the patient was pleased with the shape and color of the teeth, position, lip support, and color of the denture gums. 

Your notes say “Wax try-in, delivery of maxillary denture and bite adjusted.” It might sound silly to include the words “patient was happy with results,” but it’s crucial. Without it, you have nothing but your word (and perhaps a witness of your clinical team member). But how reliable is that in a court of law? 

Adding those details is much easier than defending yourself from a lawsuit. We all know that anyone can start a lawsuit for anything, even if you are well documented.  

No matter what the argument is - with your detailed clinical notes, you can have science on your side! 

With this evidence, you can prove when you tried to schedule a patient for the procedure the first time, how the patient’s medical history could have affected any kind of outcome, and why it was necessary. These details can be really valuable.

Presenting clinical notes in any kind of legal case is crucial to prove that your dental practice works ethically and legally. In other words, your clinical notes could save your entire practice - your employees, your dental license, and your career.

3. Dental clinical notes can help you keep track of patient oral health history

Whew, that was some heavy stuff! On a lighter note, clinical notes can make it easier to keep track of a patient’s oral health history. This can help you provide high-quality treatment, and create a relationship with your patient.

When you have a patient’s entire oral health history laid out for you, it can make it easier to create a plan of treatment. You know which parts of their own oral hygiene habits have improved or require a bit more attention on their part. 

When you have notes from every single time a patient visited for an appointment, you know their history, how they react to certain drugs you give them, how they typically pay for treatments, and everything else you’d need to know to tailor treatment specifically to that patient. 

Ready to learn more about how documentation can make you more money?

As we said - always over-explain when it comes to your clinical notes and any kind of documentation. Whether it’s to avoid claim denials, to act as evidence on a legal basis, or to make your job easier - dental clinical notes are something that shouldn’t be passed over.

Paperwork isn’t fun, but it can save you a lot of time and trouble in the long run. And it can help you make more money from insurance claims. Dental ClaimSupport has an education platform, Dental Claims Academy that can help train your team on clinical documentation and its best practices. 

You can also learn more about how important attachments or documentation are as a whole by visiting our Learning Center.