#8 – Making Clinical Notes to Summarize Letters From Dentists | Dental Practice Coaching

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#8 – Making Clinical Notes to Summarize Letters From Dentists

Transferring information from a dentist letter
The information in these letters is very important to the treatment history of the client. We don’t want to keep the letters on file, but we do want the information. Your task is to read, understand, and transfer the necessary information from the letter to our ledger sheet in the patient chart.

The yellow treatment sheet is one of our most important written records, so please follow the guidelines before writing in the treatment sheet. Have the Team Leader help you if you have any questions.

General Format
Begin with the date, then the dentist’s name.
Date/ letter from _______.

Next, what did they see/do, on what date
Client seen for (ortho exam, root canal #4, extractions of #1, #16,#28, #32 etc.) on ______.

Just summarize this part. If you write down everything in the letter, you’ll take up too much room on the ledger sheet and it takes too much time to read.
Include any comment about the treatment by the specialist, such as: Treatment went well, was very difficult, poor result, because, etc.
Include any instructions for us, such as: Evaluate for filling on #6, time for cleaning, etc.

Your job is to contact patients for follow up as needed – and document this as well as a separate chart entry.

Turn in original letters and copies of 3 summaries to Dentist for sign off:

____________________________________ _________________________
Dentist Date