Taking radiographs is a routine activity in a dental practice, and so is reading those films and sharing what we see with our patients. What isn’t so common is chart notes that reflect the actual things that occur when we take radiographs. Over the years I have seen a variety of chart entries in regards to dental images. Some offices only notate that x-rays were taken in the patients ledger, or completed procedures as they have to post the procedure code to charge the patient and bill the insurance. Other offices record in the clinical notes that films were taken and might be specific enough to mention which type of films and how many were taken. The most critical element of radiographs is rarely if ever mentioned in a dental record, and that is the act of reading them and then a clear diagnosis of the films. Anyone who has ever had imaging done at a hospital, physicians office or imaging center has seen a radiology report. The components are very clear and are designed to create clear communication and documentation. The essential components of a radiology report should be a routine element of our dental chart notes.
- Imaging Description: In dentistry this would be 4 Horizontal BWX’s, FMX or other common identifiers for the images we take.
- Clinical Indications: Why did you diagnose the need for imaging, so are we looking for caries, following interproximal bone levels, assessing periapical health, etc.
- Image Findings: What was the diagnosis from reading the images, so no caries detected, no periapical lesions and normal interproximal bone height. At a minimum you should say all images WNL’s to document that you read them.
Years ago I began this process and have continued the practice since. There are many benefits, not the least of which is the medico-legal protection of always having thorough chart notes that include a diagnosis. The better our chart notes the better our continuity of care fr patients and the easier it is for the whole team to be on the same page around patient care.