Do you know the difference between diagnosis and treatment?


For the last two weeks I’ve been assisting a colleague who experienced a stroke. I pray his recovery will continue to steadily improve and he will regain health in body, mind and spirit. Following after another Doctor always brings to mind the fundamentals of chart review for me, which I’d like to share with you today.
After your review of your medical history and current vitals, verify the treatment you will be performing on today’s visit. Please obtain not only verbal authorization, but written permission as well, being certain to ask and answer the patients questions about why the procedure is necessary. This leads me to the most crucial part of your documentation criteria. Before you initiate your treatment, you must make a DIAGNOSIS as to the reason this treatment is being performed. Examples of diagnosis would be: Carious exposure of tooth, non-restorable fracture of mesial marginal ridge, periodontal involvement of distal root, etc. The diagnosis is then followed by a written description of the treatment that is to be performed. Treatment examples would be root canal therapy of tooth # , full coronal protection of tooth#, extraction of tooth #. It is extremely important that a separate entry with the words DIAGNOSIS and TREATMENT be entered. When you accurately document these two entities you, not only meet the highest standards of care in the profession, are certain to have answered any questions that may arise when your charts are examined by anyone that may read them. If you have any questions about this or any other matters regarding documentation, please send me a note at catharine@catharinegoodsondds.com

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