*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.
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.
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!
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!