Treatment History Notes make up the major portion of your required record entries. While documentation of actual clinical interactions with patients is mandatory, all interactions should be recorded. Clinical interactions are actual appointments during which treatment is planned and/or rendered. Non-clinical interactions include all other activities relevant to your patient (telephone conversations, consultations with faculty, appointment arrangements, cancellations or failed appointments, personal observations, etc.).
Treatment history notes should contain facts and avoid the use of statements that convey judgment of the patient or their behavior. When appropriate you may quote the patient in the progress note to be certain that you have accurately conveyed their sentiment.
A template note is utilized by each student who enters the factors of the treatment delivered for each of the appropriate sections. Any contact with the patient that involves dental care decisions or scheduling appointments must be entered into the record within Contact Notes.
Decisions regarding releases, transfers, referrals, etc. are often based on non-clinical activities such as cancellations, failed appointments, and telephone conversations. The assigned Patient Services Coordinator (PSC) is mostly responsible for these entries into the patient record, but you may be asked to enter any supporting information into the record to assist the PSC in addressing these non-clinical entries into the record.
