Tips for improving your charting skills in special cases
Sometimes you need to be more thorough than usual when charting patient notes, especially when a patient refuses a proposed treatment plan. When a patient does refuse a proposed treatment plan you should make sure that you have charted the treatment, which you recommended. Also make sure to chart that you have discussed PARQ and be very specific to what was discussed.
If seeing a patient for emergency needs only, make sure to chart your advice to have a full exam and films done.When seeing a patient who has periodontitis, make sure that you chart all conversations with the patient especially the risk of bone and tooth loss. Chart if the patient refuses more frequent recall or other treatment plans. Give and chart further options of second opinion or referral to a specialist.