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Checking the note for medicolegal omissions

3 min readFor clinical staff

After End, Rebrief reads the finished note against the whole visit. It looks for two kinds of problems a dental records review would catch.

  • Details the visit implies but the note doesn't say, such as the anesthetic, consent, isolation or post-op instructions. Each one appears in the note as a faded line you can add or skip.
  • A line that can't be right beside another line of the same note. Each one is underlined in red for you to check.

Most notes get nothing. That's normal.

Missing details

Rebrief suggests a line only when all of these are true.

  • The visit implies it. A composite implies etch and bond, for example.
  • Nothing in the visit mentions it.
  • Nothing said in the visit contradicts it.

It suggests at most three lines for a note.

Adding or skipping a line

Each suggested line sits in the note where it belongs, in faded text. At its end are a shield, Add and Skip.

  • Point at the shield to read why Rebrief suggests the line.
  • Add makes the line part of your note, as your own words.
  • Skip removes the line.

From the keyboard, Tab adds a line and Esc skips it. The keys act on the line that shows them beside Add and Skip. If the line joins a numbered list, the steps renumber.

Adding a line is your word that it happened. Read each line, and only add what was really done.

Lines that disagree

Rebrief flags at most two lines in a note, and only glaring ones. For example:

  • A diagnosis the note's own test results rule out.
  • One tooth given two facts that can't both be true.
  • Two different numbers for the same thing, such as the number of carpules.

A flagged line gets a red dotted underline and a red shield at its end. Point at the shield to read why, and which lines it disagrees with.

  • If the line is wrong, edit it. The flag goes once the line changes.
  • If the line is right, select Dismiss.

Rebrief also flags a baby-tooth number that nobody said during the appointment, so you can check which tooth was meant. This check runs with FDI numbering, and not for children.

The chip on the note's bar

A chip with a shield on the note's bar shows where the check stands.

  • Before End it reads Checks for medicolegal omissions at End.
  • While the check runs, the whole chip shimmers and reads Checking for medicolegal omissions…
  • With nothing to check, it reads No medicolegal omissions found.
  • With something waiting, the chip turns red and counts it. It reads like 2 medicolegal omissions to check, 1 inconsistency to check or 2 omissions, 1 inconsistency to check.

On a narrow note, the chip uses shorter words, such as 3 to check, or just the shield.

Select the red chip to go to the first faded line, or else the first flagged line.

Good to know

  • A faded line is not part of the note until you add it. It is not saved, and Export leaves it out.
  • The check reviews the note on the Note tab. Notes written on your templates are not checked.
  • If you select Regenerate after End, Rebrief checks the rebuilt note again.
  • An older note that was never checked shows Check for medicolegal omissions. Select the chip to run the check now.