Archive for the ‘Practice Management’ Category

The Clinical Record, the Ultimate Communication Tool

Monday, June 11th, 2012

By Dr. Roy Shelburne

The true success of the dental practice hinges on good communication.  The method and rate of exchange of information is one of the greatest determiners of patient satisfaction, office morale and ultimately successful outcomes in the clinical treatment of our patients.  Good communication leads to success and the better the communication the better and higher the level of success.  Bad communication leads to varying levels of frustration and confusion with a complete failure to communicate leading to a “crash and burn” scenario.  My hope is that learning how to communicate more effectively is a goal of every practice and methods of improving communication is an area of focus of the practice.   To highlight the importance of good communication, let’s look at communication as it relates to the clinical record and how excellent communication may lead to greater satisfaction, increased reimbursement, reduced stress, and better clinical outcomes for the doctor, the staff, and our patients.

Take, for example, an oral cancer screening performed during the patient examination and recorded as part of the patient’s evaluation.  In fact, the ADA’s CDT nomenclature states:  “This (D0120) includes an oral cancer evaluation and periodontal screening, where indicated, and may require interpretation of information acquired through additional diagnostic procedures.”   An oral cancer screening should be performed “as indicated” as part of the evaluation process.  What is “as indicated”?  My interpretation of “as indicated” would be for every patient that presents to the dental office who might be at risk for oral cancer…and isn’t that every patient?  With an increase in the number and severity of oral cancer cases observed in today’s environment, it’s just good for our patients.  Performing an oral cancer screening doesn’t take very long to perform and, in my opinion, the time taken is well spent.  How then, is the oral cancer screening and its result communicated?  How is it recorded?  My recommendation requires that the doctor and team member work together to perform and record the oral cancer screening.  (Working together, hum…what a concept!)  Here’s how I suggest the system be implemented.  The doctor, during the examination, explains to the patient that he/she will be performing an oral cancer screening.  The doctor then proceeds to perform the screening and verbally communicates that “Mr./Mrs. Patient, I’m taking a look at your tissues here to see if there are any suspicious areas in your mouth.  I see here on the roof of your mouth, there is a red, blistered looking area.  What can you tell me about that?”  The patient responds, “Oh, I burned that last night.  I bit into a piece of pizza that was too hot and it burned me.”  The doctor then responds, “Sorry to hear that.  Typically burns like this heal in a week or so.  Please, if it doesn’t heal by next week, give me a call and I’ll want to take another look.”  All the while this conversation proceeds, the office staff is taking note of what is said and the information is recorded in the clinical record.  This note establishes the cancer screening was done as well as records the outcome of that exam and notes any recommendations made by the doctor.  The clinical record is complete and the criterion necessary to bill for and be reimbursed for the clinical evaluation has been met.  Certainly, the standard of care has been achieved and the patient is very impressed at the thoroughness of the doctor.  The team is working together with one goal; complete, comprehensive and excellent care for the patient.  This information has been recorded by a well trained staff member and the patient’s needs have been met.

The scenario above is a single instance where a system of communication may be implemented to meet the needs of the patient and provide excellent care.  I encourage you to examine your practice for similar situations were communication can be improved for the betterment of your practice and for your patients.  It’s just good practice.


Dr. Shelburne is a 1977 graduate from the University of Virginia and 1981 Honor Graduate from Virginia Commonwealth University’s School of Dentistry.  After graduation, Dr. Shelburne opened his practice “back home” in his grandfather’s hardware store building and practiced there for 27 years. He has been a past president of the Southwest Virginia Dental Society and has volunteered at Virginia’s various MOM projects across the state. Dr. Shelburne specializes in record keeping and business systems that protect and defend.