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The 3 Worst Mistakes You Can Make When Using Digital Charting

When implementing any kind of software, it is important to be trained fully and learn exactly what the software is capable of doing for you. You and your team require an adjustment period, in which after training, you become more familiar with the system and how to properly navigate it. You learn the functionalities and how those functionalities will make your office more efficient, and from that point on, you start using the new system.

If you’ve been using the system for a while – a few months or a few years – it is simply too easy to make mistakes, but not the type of mistakes that would require a tech to come in and help; these are mistakes that maybe you didn’t even know you were making that affect the efficiency, documentation, and security of your patient data. The mistakes might even convince you that adopting this new system into your office only made things worse.

At this point, it’s time to take a step back to remember that not everything you learned about the system stuck with you once the training was over and that it is impossible to cover all the system intricacies during the initial training. Because these holes exist, mistakes are made. This post will go through the three worst mistakes you can make when using digital charting and how it’s possible to rectify those mistakes by simply filling in those holes.

1. Not doing proper and full documentation

“Criteria for good recordkeeping include that records must be clear, concise, unbiased and objective, free of abbreviations (other than those widely accepted within the wider body of the profession practicing in that area of health), legible and accurate.”

Unfortunately, without the full knowledge of what your digital charting system can do, you might be prone to mistakes, such as incomplete and inaccurate documentation, including not documenting the full conversation between you and your patient, not documenting exactly what you’ve done with that patient right down to the smallest details, and not reviewing and completing notes in a timely manner. Mistakes like this can leave you open to civil legal action.

Technology in the form of digital charting can make doing full and proper documentation very easy and less monotonous, but if you don’t know what your system can do, you tend to miss out on these types of benefits.

  • Creating note templates that you can come back to and use later, updating with specific patient details each time you use them.
  • Without having to write everything out for each patient, digital charting gives you the tools to do the background work on a note, allowing you to document the conversation with the patient more comprehensively, including treatment options discussed.

You are responsible for the notes written on the chart and you will be expected to come back to these documentations as you continue to work with the patient, so the more clear, concise, accurate and detailed, the better.

2. Not having all your charts backed up properly 

One of the biggest mistakes when using digital charting involves the safety of all the information in your charts. This includes backing up your data properly and updating your hardware and software when it’s necessary to do so.

It is just as important to use the digital charting software to its fullest capacity as it is to makes ure the data in those charts is safe and secure.

If your digital charts are not securely backed up right now, this is a mistake that can be easily remedied by choosing either an offsite backup option or an option provided by your tech. But data safety also requires you to ensure that all your hardware and software is sufficiently updated and upgraded as to avoid vulnerabilities.

  • Make sure to maintain and update all your computer equipment.
  • Look into and implement an effective anti-virus and firewall protection
  • Add logins for the computer and for your practice management software per staff member. Logins give that extra layer of security that privacy officers are looking for.

Vulnerabilities can also come in the form of an unlocked computer in the office. Your computer screen makes all info visible for whoever walks past, if unlocked. You need to know who’s accessing, observing as well as tracking who did what. Logins can make these things preset, allowing for a username and password to be the only way to enter this locked space.

3. Not taking advantage of efficiency when using digital charting 

At the start of this post, I discussed the possibility of documentation mistakes being made without full and complete understanding of the system. If you don’t enhance, shift, or rework processes and tracking to fit the digital system that you’re using, efficiency suffers, whether it’s front desk, hygienist or communication. Without knowing exactly what your digital system can do, and without making the proper changes and adjustments to accomodate it, you and your staff are going to end up feeling busier and more overwhelmed and you will lose out on time and a much more efficiently run clinic.

With the digital charting system in place, you could taking advantage of those graphics on the diagrams, beyond what’s extracted or the occasional crown. What about the proper color markings for present and future? All your images will be all marked and updated.

Your hygienist can rely on speaking to a computer rather than another staff member to write down measurements, reducing the risk of humar error.

No more hunting for a specific chart or worrying about playing telephone between the clinical side and the admin side when it comes to booking a certain amount of time for a patient procedure.

How to avoid these mistakes

First, it is important to remember that during a training session, no matter how long, you are going to forget certain details. There is a lot to remember in a 4-8 hour stretch, and even though, our brains can retain a large amount of information, when it comes to using it in practice, we suffer with memory gaps.

The best course of action, if you’re not entirely sure if you’re using your system to its fullest capacity is to ask your software provider and discuss your processes versus what your software is made to do. This is especially the case if you find that the software is only making things harder for you and your staff. Technology is supposed to simplify and ease the workload never add to it.

However, it is also incumbent upon you to ensure you are making the proper changes and adjustments in your office to accommodate the new system, including reworking certain older processes and upgrading older technology, and ensuring that all your digital charts are secure by being properly backed up.

Resources 

https://onlinelibrary.wiley.com/doi/full/10.1111/adj.12258

https://www.mgma.com/data/data-stories/getting-your-documentation-done-what-works-best-f