Either you are a beginner in the dental hygiene profession, i.e. a dental hygiene student, unsure of the best way to write good quality notes, or a long time practising dental hygienist looking to improve his/her note-taking skills, writing notes can be a daunting task. Documentation is very important in dental hygiene therapy as not only are they legal records, they also help the dental hygiene professionals keep track of the patients' progress with their oral care and oral health. Good quality notes reflect good quality practice and patient care. So how can we improve upon our progress notes?

At Kiroku, we offer numerous clinical note templates like the periodontal treatment and examination templates that have been developed in conjunction with specialists like Dr Reena Wadia and based on guidances like the Healthy Gums Do Matter Toolkit supported by the British Society of Periodontology. They aim to offer dental professionals a faster, more accurate and detailed way to document dental hygiene notes and we will review the different sections of our very own hygiene checkup and treatment template in the article below.

Here are our 7 tips to writing good dental hygiene notes:

1. Ensure that your notes address patients’ main concerns

First things first, good dental hygiene notes should include any chief complaints reported by the patient as the main title. This can be any symptoms that the patient is currently experiencing (common concerns include tooth pain, bleeding gums, bad breath, staining and sensitivity), a previous condition or diagnosis that the patient wants to address or any statements that the patient might make as his/her presenting complaint at the initial visit. Ideally, the patient’s own words should be used as much as possible.

2. Be thorough with history taking

Good dental hygiene notes should also be comprehensive and include all the important information like medical history and social history. The patient’s health history is an important guide to link any health issues as associated risk factors to their oral health. Health conditions like diabetes and cardiovascular diseases are linked to periodontal disease and therefore will need to be considered when forming a holistic and tailored treatment plan for the patient. Another condition to look out for is pregnancy as it can exacerbate gum disease. Besides that, medical history can help improve the management of patients in the potential event of a medical emergency hence it should be reviewed and updated at every visit. If there are no changes in their medical history, ensure that it is jotted down in the notes.

It goes without saying that smoking is bad for the patient’s overall health including oral health. It puts patients at higher risks of getting a periodontal disease while worsening any pre-existing periodontal disease. Therefore, making a note of patient’s smoking habits as part of their social history is important and of high priority as well.

3. Use a systematic approach

A recommended method for healthcare professionals to document notes is SOAP. It is the systematic format of Subjective, Objective, Assessment and Plan. You can read up on how to write SOAP notes on our article SOAP Note: How to write soap notes with examples.

Otherwise, the standard format of a new patient assessment and dental exam should follow:

Complaining of and History of Presenting Complaint:

Medical History:

Social history:

Dental history:

Extra-oral and Intra-oral examination:

Periodontal examination:

Special investigation:

Diagnosis and treatment plan:

It is also useful to develop a systematic approach to carrying out the periodontal examination, the template that you use should reflect the chronological order of the periodontal assessment to ensure that you do not miss out on any part of the examination. An example of the template we use at Kiroku is:

4. Include type of dental treatment performed at each visit

To achieve accurate treatment notes, the type of dental treatment given at each visit would need to be elaborate as they will be referenced in future appointments. The treatment due for today's appointment should headline each progress note, followed by the step illustrations of the treatment given. An example of a more detailed note of the treatment given is as below:

It is also important to note any changes in periodontal assessments at each visit like the plaque and bleeding scores, mobility and furcation involvement as part of monitoring the progress of treatment.

Don't forget to end your progress notes with the plan for the next appointment including the treatment due (scale and tooth polishing, further non-surgical hygiene phase therapy etc.) and any re-evaluation that is needed (6PPC, Modified plaque and bleeding score). If the dental hygiene treatment has ended, including the patient's recall frequency for periodontal maintenance (three, six, nine or twelve months).

5. Record each discussion

Any discussions with the patient about the proposed treatment plan, risks and benefits, costs and potential sequelae should be recorded.

If Oral Hygiene Instructions (OHI) were given, the notes should reflect the patient’s current oral hygiene regimen and personal hygiene habits like their toothbrushing habits, their toothbrush type (electric or manual toothbrush), type of toothpaste, method of interdental cleaning, frequency of mouthwash use and so on. These can be under dental history in the initial examination notes.

The content of OHI given should be included in the notes as well, detailing each piece of advice given for the recommended oral hygiene regimen, for example, electric toothbrush and fluoride toothpaste use, interdental cleaning tools, proper technique of toothbrushing, soft toothbrush bristles use for pregnant patients etc. An example of this would be:

6. Use appropriate guidelines (HGDM)

Published guidelines are your friend when it comes to writing patient notes for medico-legal purposes, hence it is always good practice to familiarise yourself with the local or national guidelines to incorporate in your daily clinical notes. The Healthy Gums Do Matter toolkit, published by the Greater Manchester Local Dental Network and supported by the British Society of Periodontology (BSP), is a prime example of an appropriate guideline to refer to when deciding what to include in your notes. It includes information on the different periodontal assessments, patient engagement and periodontal treatment pathways and so on.

7. Use pre-formed templates

Last but not least, pre-formed clinical note templates are a useful chairside guide as they not only ensure that you include all the important details for each patient’s notes, it also saves you a lot of clinical time typing up your notes so that you can focus on treating your patients. If you don’t have your own template yet, you can sign up to Kiroku for a free trial as we have plenty of stock templates for you to choose from. Our hygiene exam template was made using the HGDM toolkit but you can edit it however you want to suit your own style!