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Dr Chris Harper
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Exam reports

3/2/2018

2 Comments

 
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In preparation for my move to Exeter I am slowly working through a long list of ideas to research and rethink so that when I start I can hit the ground running doing dentistry the way I want.

One big idea I am toying with is a standardised examination report, a bit like an MOT report for the pts mouth, which I believe will have a whole host of benefits. I am presenting it here now as I think it is a good idea to discuss but also because I acknowledge that others may already be using a similar idea and they may be able to expand on this idea which will help me too.


It will work like this:
On a word document I have a basic examination report template that will get completed by the dental assistant as I go through the examination and call details out to her. At the end I can then present this document to the patient and use it to ensure all problems are discussed systematically which can be done in various ways, whether that is on the computer screen, printed out or simply transferred to a tablet via bluetooth. I am currently planning on using this last method as it will leave the main computer free for the nurse to do other tasks or take further notes about the conversation I am having. I also like the fact that using a tablet will allow me to highlight different parts but keeps the process paper free. At the end the report can be emailed to the pt, or if they decline that then you could always print a copy for them to take away.


One huge advantage is that this report already contains almost all of the information you would plan to put in the pt notes so just copy and paste and then you only need to add small details such as discussing OHI etc and what the outcome of the conversation was regarding how the pt wishes to proceed.


Initially it might seem like this will involve a lot more work than a "normal" exam, but having tested it I believe this should consistently all be possible in 20 minutes assuming that things like MH and the chart are upto date. When I start in Exeter I plan to allow 30 mins for all initial exams so that I have more time to build rapport and because I also want to ensure all pts have good photos taken as well, which will go hand in hand with this report making it even more powerful.


I strongly believe that this kind of template will achieve the following benefits:
Better, more complete examinations.
A very high standard of documentation.
Improved discussions with the pt ensuring they are more aware of their current situation and its' implications.
Subsequently it is highly likely that more pts will be interested in the options I am suggesting therefore increasing case acceptance for the interesting dentistry I wish to carry out. And this more comprehensive style of dentistry should result in better maintained pts and higher revenue as secondary benefits.


If you already do anything like this and have any pointers, or if you have any thoughts about this process whether they are good or bad I would love to hear them.


Please excuse the formatting errors on the phone screenshot. If you want to download the word version please see here:
https://drive.google.com/open?id=1A_NwMDlV73Vz5CJgV9UdvktsbMiFvSYj
2 Comments
Peter Costello
5/27/2022 10:17:21 am

Thanks Chris for the content. How have you found the use of the printed MOT after a period of time? Has it evolved?

Reply
Chris
5/31/2022 08:31:26 am

Hi Peter,

Thank you so much for taking the time to read and then comment.
You are right that this process has evolved a lot over the last few years.
From the outset I found it very helpful and I was able to make much more comprehensive notes than before and subjectively (coupled with taking photos for pretty much every patient the first time I met them) I felt I was able to do a much better job of explaining to people what I was seeing in their mouth.

The main evolutions for the exam report are that I am now using the Kiroku software to record my findings rather than a word document. It is even quicker and simpler meaning that I can record so many more fields in a standard exam. Then that just gets copied and pasted into their notes. Or if it is a complex case then I now have a slightly more detailed report that I create and generally email to the patient. In that report is a basic summaryof their situation (looking very much like the exam report as it did in my blog post). But afterwards are their photos and a more detailed explanation of my findings. Eg if they have deep caries I use the phrase express program and a few keyboard shortcuts to elaborate on what that means for a tooth. I also include in that a final section which I used to give as a separate info sheet called "general info for complex treatment" which discusses about financial consent and teamwork when choosing shades etc
So in total the report is normally 4 pages long (summary, photos, more detail, general info) and it gets saved as a pdf. using kiroku and phrase express the whole process of creating the report and emailing it to the patient normally only takes 5 minutes max but feels so far above and beyond what I was doing previously. It isnt needed for most patients but if they are complex I think it is so useful.

If you would like to see an example of such a report i can email you one when I am back in work next week (I am off for this half term to be with the family).

Can I ask what drew you to this blog post? Are you doing something similar or considering overhauling how you carry out your exams?
Best wishes
Chris

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