doctors: are your assistants responsible for writing your clinical notes? why or why not?

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No! It’s your license at the end of the day. When you get sued, the assistant is not responsible for your laziness. In the medical field, everyone licensee writes up their own notes. Be responsible, after it is YOUR license.

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As a dentist, I agree with you. My notes are too important to leave up to anyone else and my assistants have their own job to do. Granted, my notes tend to be more involved than other dentists I've worked with, but the details I have included have proven helpful frequently enough that I'm not about to get lax about it. It might feel tedious and I might just want to go home, but quality documentation completed specifically by me (so that I don't get in the habit of scanning and approving) is important to me as a provider. I'd rather produce less but know that I have everything done correctly and to my standard than to take what many would consider harmless shortcuts.

Most will never suffer negative consequences over things like this, but it's just not worth the risk to me. I don't look like the "traditional dentist" so I'm regularly subject to scrutiny many of my colleagues are not. Race, gender, age, etc can be seen as things that make some providers appear to be easier targets, in my opinion. It's not right obviously, but I'm not going to make it easy for anyone who thinks they're going to pull one over on me.

We do our notes in the computer. Assistants start the note and put in as much info as possible, the dr will review the note, add to it or revise it and then electronically sign it. Most of the assistants start the note as soon as they seat the patient because we have note templates for each procedure. Seems to work well for us.

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This is our way too. Seat, review medical info changes, start template... inform doc of any changes and who pt is and procedure, then finish notes at end of procedure. If it was a more complicated procedure or I wasn't sure about what was discussed in room if I stepped out, I ask doctor and modify the note, and she will go back in if I ask her too.. I have 16 years DA experience

Most assistants write doctor’s notes using premade templates which are a few clicks. Sometimes an extra line or two are added. Scenarios that require a little more extra, I’ll write myself. Is there a reason you’re asking? Just curious.

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I agree but saying notifying the office manager kind of makes me chuckle. These official “positions “ mean nothing to a DDS grad. I am a RDH that has a Bachelors degree in business as well (8 years of college….same as a DDS), but you think a new grad DDS recognizes the “authority “…..not even close.

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I agree as an assistant we can write notes if we have time sometimes we are super busy and drs write notes on down time we have premade templates that I place and I fill in especially for NP but I work in a busy practice y'all could handle tht

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At the end of the day the dentist is responsible for the chart notes. We have pre set templates for all procedures. In my office I have the assistant write the notes add any information they hear between the dentist and the patient. The dentist must review/ modify and sign before they leave.
My hygienists do an excellent job with their notes. The doctors don't really modify or review the notes but they should.

It doesn't mean a dentist is lazy if they're not doing the notes, it means they're busy and they're not going to talk to the patient and type/write at the same time. At the end of the day the dentist may not remember every single detail that's why the assistant would be the one writing the notes.

Now as for the dentist who doesn't check if the notes were done ( or done correctly), then that's negligence and irresponsibility.

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So as a manager lighten patient flow, because to say they don't remember, but must review "what they don't remember is dumb! NOTES are not a DA jobs we are not skilled to do so. so yes the dentist is lazy stop trying to use short cuts. This is the type of office I wouldn't work or let them touch my mouth!

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I graduated from Florida career college about a year and two months ago but I haven’t used my certificate so I have no experience.. how do I get into a Dental office without any experience other than my schooling and externship and one week a dental office!! How do I get in ??

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You can also ask if they need help, you could donate time and gain experience in the field. Also applying for a job can be easy too, you can tell them your a quick learner and can learn they way they do things. 😉 Good luck!!

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