While many claims in the courts for damages against dentists can at first appear easily defensible, it all too often emerges that any defence has been seriously compromised by poor record keeping.
Understandably, as dentists, we consider ourselves to be clinicians rather than scribes, but this attitude and its consequences play right into the hands of the plaintiff’s lawyers.
The dental record is often the only item that can show why a particular item of treatment was undertaken. Five minutes spent writing up the notes after an appointment can make the difference between a good night’s sleep later on and a formal complaint. A good contemporaneous record will never let you down, whereas a poor one might just as well not be written.
These are the main things that should be included in every patient’s clinical record. The list is not exhaustive, and other items can be included:
• An accurate, contemporaneous record of all aspects of clinical data.
• Models, radiographs, photographs and periodontal charting.
• Consent, warnings, medical history and any correspondence.
• A record of investigations.
• A record of payments.
• Other relevant information.
Each entry in a dental record should be dated, and should contain sufficient detail to enable any suitably qualified clinician to understand exactly what process was undertaken and why. Very often it is not the material that is written in the record that is significant, but what has been omitted.
Do not underestimate the importance of the patient’s social history either. A social history is rarely taken down, but it can have tremendous significance in TMJ and occlusal cases in which stress is a causal factor, or in ones in which it is important to take into account the patient’s occupation before carrying out a procedure that carries with it an associated risk of nerve damage.
Make use of IT. Computerised record-keeping systems are fast becoming the norm in modern practices, but make sure your choice of software includes an audit trail that shows when a particular entry was made, and that the entry cannot be changed afterwards. There is little point in relying on a particular record, irrespective of whether it has been changed, if its integrity can be challenged.
A record can soon become extremely bulky if you do not use abbreviations in the notes. There is no real problem with shortening commonly used phrases as long as you can show later on what they mean. Many clinicians develop their own shorthand but you must ensure someone else in the practice can interpret it too.
I can perhaps best illustrate the importance of these points with a case study of a simple situation. A dentist recently received a telephone call from the headmaster of a local school asking if a particular teenage pupil had attended his surgery that day for an appointment for an extraction.
Apparently the child had a history of truancy, and it was suggested that this was just another ploy to explain his non-attendance.
On this occasion the child had, in fact, attended the surgery, but without his mother. The dentist pulled up the patient record on the computer, and was about to provide the information requested, when the practice owner, who had come to discuss another matter, happened to overhear the conversation.
Fortunately, before the information was released, the practice owner realised that an issue of confidentiality was involved. So the headmaster was stalled for a few hours while the mother was located and her parental consent for release of the information was obtained.
Acting in the patient’s best interests prevented disciplinary action by the school against the boy and, coincidentally, the possibility of a professional misconduct case being brought against the dentist for a breach of professional confidentiality.
I hope this shows the fine line that exists between acting in a professionally unimpeachable manner and leaving yourself open to all sorts of legal horrors. The measures outlined here are simple and easily achievable, yet they can save you untold thousands in solicitors’ bills and lost business.
Dental Protection’s series of risk management modules has now been expanded to cover 36 of the most common areas in which practitioners experience problems. The series
is available in printed format and on CD, and comes with verifiable CPD. For more information, log on to www.dentalprotection.org
