That’s according to new advice from the UK-wide dental defence organisation, MDDUS.
A new year offers people the ideal opportunity to replace bad habits that, for some dentists, means improving their note keeping in dental records. MDDUS dental adviser Claire Renton believes that taking the time to ensure records are kept up-to-date can be invaluable for dentists on the receiving end of a patient complaint.
Claire said: ‘It’s fair to say that if it’s not in the records, then the assumption is you didn’t do it. Memories fade and the only way to be sure of what you did and didn’t do is to write it down.
‘It is vital dentists make time in their busy schedule to update their records. Good notes are important in recording the overall management of a patient and help improve patient safety. It can also be the cornerstone upon which defences are built against complaints and claims.
‘Take a note of what you discussed with the patient, particularly if the treatment is complex or expensive. Record the treatment options you discussed and record what warnings you have given to the patient concerning likely prognosis of treatment. For example, if the treatment is available on the NHS but the patient opts for private treatment – clearly mark this in your notes.
‘Make sure you record positive and relevant negative findings. If something does go wrong with any treatment, and occasionally they will, tell the patient and make a note in the records that they have been informed.’
• Write it down– always
• Update records
• Record discussions with patient
• Note complex or expensive treatments
• Record any treatment hiccups
• Ensure you note negative and positive findings
• NEVER rely on memory – civil cases can take years to come to court
While you may not be able to prevent complaints or claims being intimated, you can minimise the repercussions by keeping good notes.
‘There can be a significant time lag before such issues arise and you will unlikely recall the consultation in full detail,’ added Claire.
‘It is common for civil cases to take a couple of years to come to court once an action is raised. In a litigious setting, notes are far more reliable than your memory. Would you really remember in detail a root canal treatment you carried out from three years ago?
‘At MDDUS, we have to settle many claims because the fundamental basics are just not there. Records serve to demonstrate professional integrity and justify courses of actions in the treatment process.’
While you may not be able to prevent a claim or complaint being intimated by a patient, you can minimise the repercussions by taking good clinical notes.
‘If you are in any doubt about the requirements in relation to contemporaneous notes, contact your dental defence organisation for assistance and guidance,’ added Claire.