Upping your game
As dentists, we are great observers of detail. However, we often do not transfer those observations to our written clinical records. Most of us are guilty of settling for what I often am forced to recognize as terrible dental notes. I think it’s easy for each of us to ask ourselves and answer a simple question, “Are my notes to the level of what a physician would document for a similar situation?”
Your eyes and mind are wonderful places to start this process, but until these observations are in the written record, the process is incomplete. Medical records and medical insurance require medical grade documentation. The brief dental notes that we often write, are unacceptable for the medical world of our dental practices. It’s not a matter of trying to write lengthy notes, it’s all about the detail and using medical assessments of head, neck, intraoral and airway conditions.
One simple example for today, is to incorporate a Mallampati assessment in the written record for all your sleep cases. I’ve included a Mallampati diagram below. In your exam, make sure you always note. “Patient is Mallampati X” as one small part of your thorough airway assessment.
Start upping your game and be more detailed in documenting soft tissue, hard tissue, radiographic and airway findings. Get in the written habit of including statements of what the patient reports about sleep and how they feel during the day. Better records go along with a higher standard of practice and are often helpful for medical review by medical insurance carriers.
We discuss this, and many other aspects related to dental sleep medicine success during our online lecture, Success in Sleep.
Mallampati diagram: Class 1, 2, 3, 4.
Learn more about upping your dental notes, and managing your sleep apnea patients by attending an online CE seminar with HST America and Dr. Marty Lipsey, from Medical Billing for Dentists.
HST America is dedicated to helping dentists implement a sleep program through our innovative ‘zero-dollar sleep protocol’ and concierge home sleep testing services. To learn more about our Success in Sleep seminars, view our video below.
About the author
Marty R. Lipsey received his DDS degree from UCLA and a Master of Science from Northwestern University Dental School. Dr. Lipsey is the founder of Dental Sleep Med Systems and Medical Billing For Dentists, offering dental teams assistance in implementing and improving their dental sleep medicine practices, including outsourced medical billing and successful insurance coding and processing. Dr. Lipsey lectures nationally on dental sleep medicine and medical billing and is a full time advocate for sleep health and effective medical billing systems.