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On one of his recently articles, Dr. James Anderson emphasis that clinical notes have always been a standard for creating narratives that get claims paid. They support the necessity for the services rendered. "If it isn't written, it didn't happen" still rules the courts when it comes to proper documentation of care.
Many dental practices do not record accurate clinical notes but instead have used templated or previously used narratives to submit to the insurance companies as proof of clinical evidence. The tables are turning, and some insurance companies no longer accept narratives as documentation of treatment rendered, especially in the situation of appealing a denied claim.
Documenting the discussion and what was performed creates a story for providers that will see this patient in the future, legal, and insurance documentation and gives clarity of thought to the patient's situation at that time.
Once you build this valuable habit to provide clinical notes on every patient, it will become easier and faster. It will create the proper documentation to secure payment of dental claims and ensure adequate dental/medical records for now and the future.