Paperless Charting using MS Word

Warning: these instruction were written several years ago to work with MS Word 2003; they are somewhat dated

Bruce A. Stephenson, DDS

(Scroll WAY to the end of this page to see an addendum showing an example of our charting.)

In our office we use the auto-correct feature of Microsoft Word for “canned” charting notes. You can do the same thing with Open Office (which is free), but the directions below are specific for MS Word.

Our charting is usually done in the operatory by the chairsides. Using our MS Word "macro's, we chart the need (insurance documentation) for the treatment in the first lines of our charting, then the details of the procedures, local, etc. This is then pasted into Dentrix chart. We then immediately generate the insurance claim and copy the same entire note into the "remarks" section. Finally we delete everything in the pasted note in the remarks section except the first few lines covering the documentation for tx. Very fast, no typing, and the insurance company gets exactly the same documentation as we have in our clinical notes. We then choose the images we want to send with the claim (usually a digital pan). We use a double-tray closed bite impression for most crowns that sets in 1.5 minutes.

One of my chairsides can get all the charting done, insurance form generation done, images done and new gloves on before the impression is ready to remove from the mouth. If she does the lab slip also (a modified quick letter with more ms word automatic typing), it takes her another 30 seconds so I have to take the impression out of the mouth myself! Poor me! (no more raises until she gets a little faster!) By the time the patient leaves the operatory, all the charting is done, the insurance is billed and the next appointment is scheduled. When the patient gets to the front desk, my office manager just has to put down her People Magazine long enough to collect any money due. This is a really great illustration of how paperless / chartless dentistry is so much more efficient than a paper-based system!

Here is the step-by-step:

1. Each computer needs to be setup to use these codes. I am sure there is a way to do it across the network but I don’t yet know what it is!
2. Open MS Word and type what you would like to save; for example:

Prep; lavage with 70% isopropyl alcohol for 30 seconds; etch with 35% phosphoric acid for 20 seconds; rinse and dry; applied Gluma for 30 seconds and dry; apply Photobond; Starflow  placed along gingival margin; remainder of prep filled with Z100; pulse cured

3. high select the text you want to save, then go to “tools, autocorrect”
4.  
5. 
6. and type the “mnemonic” you want to use (here I typed “CPR”; any short series of keystrokes will work – just be sure it is not a real word)
7. for short segments such as names or amount of local anesthetic used, you should check the “unformatted” text box. For longer segments such as an exam, formatted is usually better.
8. click ok to exit the auto-correct box and proceed to the next segment you wish to “memorize.”
9. after saving several auto-correct segments, close MS Word, then re-open it. This “saves” the auto-correct segments as part of the Word settings on this machine. These auto-correct segments can then be used in any document opened by Word (and some other MS products such as Excel) on this machine.
10. when you are charting treatment for a patient, what you type might look like this: “notooth la2 fgcr bas tm pcc" but what would appear in Word would be:

Large restoration with extensive recurrent caries; inadequate amount of tooth structure remaining to provide sufficient longevity for any restoration other than casting. Two carpules of citanest with Forte 4%;  Pre-op blue mouse double-bite; Caries removal and preparation; plain cord retraction with Astrigident; blue-mouse and silicone wash in a double-bite tray; Luxatemp temp cemented with Temp-Bond;   Bruce Stephenson, DDS Terry Martinez, RDA

Plan: cementation – appointment made  

I have used different color fonts just for illustration to show the link between what I actually entered at the keyboard and what shows up in MS Word.

11. If you are using Office 2003 or a Tablet PC, you can simply “speak” the mnemonic and Word will recognize them and type them for you. However, in my hands, typing is or entering with a stylus is faster.
12. when your charting is completed in Word, select it by typing ctrl-a, then ctrl-c which copies it to the Windows clipboard
13. go to your dental note charting area and type ctrl-v (paste)
14. presto! Your charting is done … and readable!! Isn’t it a whole lot easier?
15. we have 20 to 30 of these mnemonics; different people use different ones. For example, the hygieents use their own for their “routine” charting and to fill in the “usual” answers during a re-exam. It is very easy to quickly change any of these “default” entrees before you transfer the charting into your dental software.
16. I know there are lots of improvements to be made in this system and you may get around to them long before I do! One thing was mentioned above; sharing the setup across the network so you only have to do it once, not once on each computer. Another thing would be to use a Word template to make “drop down” selections or radio buttons that would transfer into a text file from the clipboard. I am pretty sure this would work … maybe! If you come up with any additions, comments, solutions, please let me know so I can use and share them!
17. I hope this is useful. Have fun!              Bruce Stephenson, DDS 3/02  (updated 8/04)

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An Example of Paperless Charting

Bruce Stephenson, DDS

Thursday, January 27, 2005

Here is the sample of some of our charting. You can see that all the charting is attached just to one procedure … in this case the crown  … but it pertains to the entire visit.

Our lab slip which is done as a dentrix quick letter but filled out in ms word; one copy is printed and attached to the case, and the second “copy” is pasted in chart as you see. Any letter we send (to a pt or another dentist, etc) is handled the same one.

To me, the whole point of going “paperless” is because it is easier and more efficient than paper charts. This saves the office an incredible amount of time … thereby saving me a bunch of money!

(If you would like a copy of the Word Shortcuts Dr. Stephenson uses in his office, click here. You need MS Word to open this file)