*Please note that there are external links in this post but they are merely links to other articles! 🙂
In dental hygiene, as with any medical pursuit, making notes is an essential part of the job. Think back to any of your hygiene visits in the past. The chances are that the hygienists made all manner of notes, both about medical history and treatments.
When I started practicing, though, note-taking was sometimes placed in the back burner. There’s a lot going on as it is without having to worry about jotting everything down. It can be easy to get into the bad habit of not making notes until the evening. Thankfully, I’ve found what works for me and that never happened, but many practitioners face this exact scenario!
In reality, this is a grave mistake which could land you in hot water. The fact is that medical practitioners don’t make notes as they go for fun. Adequate note taking habits actually serve a few essential purposes like serving as a baseline for my patients to monitor their health and as legal evidence in the event of a lawsuit.
Protection
Perhaps most important of all is the protection notes offer me or any health care practitioner out there. When you write treatments and so forth down, you’re effectively making a record of everything you do. This can be useful if your patient experiences issues or decides to bring a medical malpractice suit against you. This may send fear into your heart, but it’s a reality that most medical practitioners face at some stage. This won’t be an issue for you if you can provide notes to prove the treatment you offered, and the condition of the patient when they left your surgery. If, however, your records are patchy or non-existent, a patient can level all manner of accusations at you (read about the power of words here), and you’ll have no way to defend yourself.
Memory
At the very least, my notes serve as my memory. When I see a lot of patients, there’s no way I can remember each one in detail. I might remember faces or certain personalities, but most of my clients will blur into one. This can both look unprofessional and slow me down. Being able to read up on notes could help you refresh on one’s past treatment and medical history in seconds, as well as a few other details that could help you establish a rapport with your patient faster!
Tracking
Notes are also a fantastic way to track a patient’s progress. This could, again, save you from legal proceedings. As well as performing hygienist duties, I need to track things like periodontal disease (click here to learn about why it’s important we as dental hygienists keep track of your dental and periodontal charting). Failure to do so means even your notes won’t save you from malpractice proceedings. Yet, the only real way to achieve this is to track a patient’s teeth over time. And, that’s exactly what my notes allow me to do. By taking detailed notes about the condition of teeth and gums, I’ll be able to see straight away if anything changes over time.
Speaking of being organized and taking notes, Medicine & Merlot has a great blog post about 5 great note taking apps. This is great for work and for school, so if you don’t have an already-established way of taking notes, be sure to give it a read!
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Lavrax says
October 31, 2018 at 8:31 amI never saw such a serious side to note taking! Especially for medical practitioners. I can’t believe how important it actually is! And I actually need to learn how to take notes because everything is really piling up. Thank you for the reminder!
Geraldine says
October 31, 2018 at 11:08 amNote taking is important not just for organization but surprisingly has legal benefits to it too! It’s so easy to take it for granted but it could help us out in the future! 🙂 I hope it helps you! I’m trying harder to be a better note taker as well 😊
Chloe Chats says
October 31, 2018 at 9:55 amGreat informative post, I can see how important it is to jot down notes in this profession! It would definitely be hard to remember everything that patients have said to you if you haven’t noted it all down. I feel like noting down things is so important for every thing really, I always forget things and so writing stuff down is super handy and helpful for me!
Chloe xx
http://www.chloechats.com
Geraldine says
October 31, 2018 at 11:18 amThank you Chloe! I feel like writing things provide not only physical evidence but it helps me remember things better too! When you see many patients it can get confusing if it’s not all on paper!
Marie says
October 31, 2018 at 2:06 pmI absolutely agree that notes are important, particularly because nobody can remember everything.
Geraldine says
October 31, 2018 at 2:57 pmYes! They are super helpful. It helps just in case we have to look back on notes years down the line 🙂
Hanna Rose says
October 31, 2018 at 4:46 pmHey Geraldine!
So interesting to see note taking from your perspective and I can see how invaluable they must be to you on a day to day basis in your job.
Being from the UK, I’m not familiar with the role of dental hygienist but I’d love to be filled in. Is it like a UK dental nurse? I’m so curious about the answer to this now! 😂
xoxo
Hanna Rose
Latest Blog Post: Bath & Body Self Care Essentials
Geraldine says
October 31, 2018 at 5:43 pmThank you for reading Hanna 😍😘 It’s often something that many of us take for granted! A dental hygienist works in a dental office and works independently of the doctor! So I do you cleanings and take x-rays and I will bring the dentist in to check later on!! But dental hygienists are the ones that really see the patients the most and are the first people to be able to detect any abnormalities or oral cancers! !😊 Thus it’s exteemeex important everything is documented! I hope that helped a biy 😅 Xx
Hanna Rose says
October 31, 2018 at 5:57 pmThat was so helpful and informative! Thank you!! Over here, the dental nurse seems to perform a similar role. The main difference is they typically work along side the dentist, seeing the patient at the same time. And come to think of it, they do usually take a lot of notes during the appointment too, it’s usually done on the computer rather than by hand.
Hope that shows you a little insight into our UK dental system. I liked learning from you about how things work in the US! 🙂
Geraldine says
October 31, 2018 at 7:31 pmoo cool! that sounds similar to the dental assistant here! They work on the other side of the dentist and usually hands them things or does stuff on the computer, or suction your mouth!! 🙂 I appreciate learning more about how it works in the UK! 😊
Shalycee says
November 1, 2018 at 3:05 amI knew note taking was important but not to this degree! Such an interesting read!! I love the flow of your writing too btw
Geraldine says
November 1, 2018 at 9:57 amThank you Shalycee! It’s def something that should be treated more seriously but when you’re in a rush, it can be forgotten! xx
Bexa says
November 1, 2018 at 6:05 amThis is a really interesting post Geraldine! I can see why taking lots of notes is really important as a dental hygienist, there must be so much to remember! It sounds like such a helpful way to keep track of medical history and quickly build rapport every time you see a patient. Thanks for sharing such a detailed and well written post, and it is such a great reminder of how useful notes really are! <3 xx
Bexa | http://www.hellobexa.com
Geraldine says
November 1, 2018 at 10:04 amThank you so much Bexa! The general population are good and there’s not too much out of the ordinary but you never know when they will come handy! The more detailed, the better! I think that goes for everything we do! 😊
Ruth says
November 1, 2018 at 6:45 amThis was so interesting to read. Even as a patient, I wouldn’t automatically think of all the ways the notes might be useful – I mostly assumed they were to track progress and keep a general record. Thank you for sharing your insight!
Geraldine says
November 1, 2018 at 10:13 amThank you Ruth! They certainly are helpful with keeping track of someone’s progress, but we don’t get to appreciate it until something big and serious happens 😅 Thank you for visiting Ruth! 🧡
Len says
November 1, 2018 at 12:36 pmReally interesting insight into your job! I never even noticed the dentist or dental hygienist taking notes, but now I’m realizing they probably take notes on the computer while I’m just lying in the chair with my mouth wide open, haha.
Geraldine says
November 1, 2018 at 1:13 pmThank you Len! Yes, we do a bunch of things that might not be within view of the patient! It gets a little awkward if we stop talking for a few minutes because we’re writing haha! I usually write my notes right after I’m done with my patient! 🙂 Thank you for reading lovely!