Dental clinical notes: 3 reasons they are crucial to your success

Dental clinical notes are a key piece of the puzzle that is dental insurance claim reimbursement. But it’s also crucial to keep detailed clinical notes for your in-house record-keeping to fend off legal troubles, and also to shape an optimal patient experience.

Clinical notes are where you document your patients’ personal and clinical information in detail. These multipurpose notes are then used as a claim attachment, added to your patient’s medical history, and included in your office’s records.

The ADA defines clinical notes and documentation perfectly: 

“The recording of accurate patient information and treatment in the dental record, sometimes referred to as the patient chart, is essential for good risk management. As a result, the value of maintaining thorough and accurate dental records cannot be overstated.”

In case we weren’t making it obvious, your clinical notes are pretty important to keep organized and at hand.

Because we offer insurance billing solutions here at DCS, we understand the high value of clinical notes, especially when our experts use them to submit clean claims for your dental business.

To make sure you understand their value, as well, let’s get into 3 reasons why clinical notes are vital to your dental business. 

And as a bonus, we’re sharing this free resource with you — Dental Clinical Notes: Your Checklist for Success. Get this small-but-mighty checklist sent straight to your email when you download the form below. You can then download, print, and share the checklist to use as your go-to guide for creating the ideal clinical notes to support your patients and your practice.

Key takeaways on the importance of dental clinical notes: 

• Add as much detail as you can to your clinical notes — what seems like too much is probably just enough.
• Your clinical notes could be the deciding point that wins a court case, eases claim acceptance, and sells treatment plans
• You’re building an in-office archive: Past clinical notes can be used during treatment presentations to recall baselines, build timelines, and increase acceptance rates

Reason #1. Dental clinical notes accelerate your insurance claims revenue

You probably know that when you submit an insurance claim, you must provide proof that the treatment performed was necessary for the health of the dental patient. You may not know that this documented proof can come in the form of: 

• X-rays
  • Periapical (PA)
  • Bitewing X-rays (BWs)
  • Panoramic (Pano) 
  • Full Mouth X-ray (FMX)
• Intraoral photos (IOC)
• Clinical charting, and  
• Clinical notes — our focus for this article

When it comes to claim reimbursement, the more details you include in your clinical notes, the better. Dental insurance companies are always searching for new ways to delay or deny claim reimbursement, and insufficient documentation is among their reasons for claim refusal — don’t make it easy for them!

When you have properly documented procedure codes in your clinical notes, insurance companies have one less reason to deny your insurance claims. Fewer denials can lead to quicker claims income, and unless you are a fee-for-service dental practice, this is likely close to 50% of your overall practice revenue. Minimize denials, and you’ll maximize your cash flow.

Read more: 10 reasons your dental insurance claims are being denied

So, it’s always best to over-explain yourself in all of your documentation, particularly your clinical notes, just to be sure. 

You don’t want to miss out on revenue just because there wasn’t enough detailed information in your clinical notes. 

Reason #2. Dental clinical notes can be used in your legal defense

Dental clinical notes can come in really handy when facing legal issues around treatment at your dental practice. 

In the dental or medical field, there will always be risk management issues. Unfortunately, when supporting people’s health as a way to earn an income, legal actions are inevitable.

But these legal risks can be mitigated when you have dental clinical notes that can act as evidence that a procedure or treatment you performed was necessary, was done correctly, and was done with your patient’s approval.

Here’s a quick example of clinical notes in a legal context: 

Pat the Patient comes in for a denture, and every step is followed meticulously: impressions, bite registration, articulator mounting, and a perfect wax try-in.

Pat says they’re thrilled with the color, shape, and fit during the try-in, but they left after the appointment without settling their bill. There was no financial agreement before the procedure, and when the billing coordinator tries to collect, Pat disputes the entire bill, claiming dissatisfaction with the denture.

This isn’t how you recall engaging with Pat, so you check the clinical notes only to find this minimal documentation:

Wax try-in, delivery of maxillary denture, and bite adjusted.

Critical details are missing, including support for your legal rebuttal: the patient’s approval of the denture’s color, shape, and fit. Without clear and complete documentation recorded at the time of the procedure, there’s only your word against the patient’s, which is not the best position in a legal dispute.

Comprehensive notes, including the patient’s level of satisfaction at each step, can be your sword and shield in a legal battle. Documenting these details takes time and effort, but it is far quicker and easier than an undocumented defense against a lawsuit. Do whatever it takes to ensure you have science and evidence for your side if challenges arise.

Presenting clear and comprehensive clinical notes in a legal case is vital for proving that your dental practice works ethically and responsibly. Imagine: A few lines in your clinical notes could save your entire practice — your staff, your dental license, your career, and your reputation.

Reason #3. Dental clinical notes can help you track each patient’s oral health history

Clinical notes will make it easier to keep track of a patient’s oral health history. A long view into your patient’s preventative care, problems, and procedures will help you provide high-quality treatment, and it can create a stronger relationship with your patient, too.

With a complete and detailed timeline of engagement, you can see — and also share — which parts of your patient’s oral hygiene habits have improved or will require a bit more attention on their part.

You will also have a record of how they reacted to specific medications, how they typically pay for their procedures and everything else you’d need to know to tailor treatment to their individual needs and preferences.

When you have a patient’s entire oral health history laid out for you in detail, it will make it easier to create a treatment presentation, too. And when you display the patient’s oral health history to them, it can make it easier for them to understand and accept that plan of treatment.

Remember: if you and your team don’t have time for a treatment presentation, you can automate parts of your revenue cycle to get more time for one-on-one time with patients. 

A personalized presentation will create a better dental experience for the patient, which is always good for your practice. They won’t feel like just another warm body in the dental chair because it’s clear that you’ve been paying attention to their needs — you know all about them!

And it’s your clinical notes that will contribute to this invaluable rapport that can gain you a patient for life.

Read more: How to have a patient-centric dental business: 3 tips (Free guide)

Make more revenue and improve every patient’s experience with thorough clinical notes: Get the Dental Clinical Notes: Your Checklist for Success

Now that you know why you need detailed clinical notes, you might be thinking, “Okay, so how do I ensure my clinical notes include everything they need?”

We’ve got your back! Fill out the form below to get Dental Clinical Notes: Your Checklist for Success sent to your inbox immediately. 

Download, print, and share this list to have on-hand when completing your dental clinical notes, so you can be assured that you’re including everything you need to submit clean claims and promptly collect all your revenue. 

See claims reimbursed faster when you turn to RCM experts

To recap, here are 3 big reasons you need detailed clinical notes for success: 

• Reason #1. Dental clinical notes help maximize your insurance claims revenue
• Reason #2. Dental clinical notes can be used in your legal defense
• Reason #3. Dental clinical notes will help you track patients’ oral health history

Remember to download our Dental Clinical Notes: Your Checklist for Success so the most detailed, valuable records are always available to you and your staff, at all times. 

And remember that comprehensive clinical notes will assist when you partner with service providers, too! DCS offers end-to-end revenue cycle management solutions, including insurance claims processing. Your designated Account Specialist will use your detailed notes to ensure you get paid what you deserve. 

Empower your team to focus on in-office patients and tasks while our team handles the tedious billing work: Book a free 30-minute consultation today.