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.
Lee, this is a great reminder for us all. We tend to get on “auto-pilot” and this review of radiographs reminds the patient that you care and the team that the radiographs are taken for a reason (not just to generate income). With the paperless charts it’s easy to have a “auto-note” declaring “Reviewed radiograph, no obvious pathology”. Done in 10 sec.
Thanks for the reminder… I’ve always entered what xrays were taken. And I’ve always made chart entries when the xray’s purpose was related to a sign or symptom, but I’ve been inconsistent in making notes for the routine bwx or fmx survey. It is a relevent finding to notate that nothing was found… as you said, it indicates that I looked them over. On the other hand, I nearly always put the xrays on the monitor and go over the xrays with the patient and any and all issues found on xrays are documented directly on them using the xray software. Yet I still appreciate the reminder because I know I’m not perfectly consistent about the chart notes when there are no findings.