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Writing detailed chart notes for each and every patient can be an arduous process, however, taking down the correct chart notes and including the correct details is an important responsibility of a dental assistant.
In this article, we’ll be covering why chart notes are so important and the correct method for taking them.
If nothing else, chart notes protect you from a legal standpoint. As Dentistry IQ points out,
“Chart notes can and will be called into evidence in a court of law if the practice is involved in a malpractice suit. The notes are legal documentation and therefore should be treated as such. Not only that, but records are often transferred to other offices when patients change dentists, and you don’t want your notes to sound like they were written by a kindergartener.”
Apart from covering yourself from a legal standpoint, the correct, and legible, chart notes are vital to getting the patient the care they need from you and any other dental healthcare provider that they choose to attend.
Here are some details that it is vital are included in your patient’s chart notes:
SOAP is an acronym used to standardize the way in which a procedure, and the circumstances surrounding it, are noted down. They are also a great way to ensure you are recoding the correct data.
SOAP stands for:
Here at Northwest Career College we firmly believe that learning is a process that continues on the job. Our Dental Assistant Training Course gives you all the key skills and experience you’ll need to find the best dental assisting employment opportunity in Las Vegas. Our Dental Assistant School offers morning, afternoon and night classes to accommodate your busy work and family schedule and our established, seasoned instructors have helped our students achieve a 91% national exam pass rate. Call us at (702) 403-1592 to speak to one of our admissions assistants about your new dental assisting career.
Written by: Cynthia Lofquist, R.D.A. Dental Assisting Program Chair Concorde Career Institute