Record keeping – It’s not going away

I can almost hear the groans this topic often elicits. Yes, it’s those dirty words again – clinical records. Hang on a minute! Please read on…
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Surely we don’t need to be reminded again, I hear you protest. There’s always someone nagging us about it. Yet hundreds of dental claims every year remind us that it’s a topic that’s not going away. Good clinical records are an essential part of contemporary dental practice. As the following claims highlight, good records help protect you against the unexpected.

Adverse patient outcomes

  • A dentist referred one of her patients to a colleague for extraction of tooth 44. While the initial conversation was had over the phone, she emailed through a written referral a few days later. However, in preparing the referral, the dentist realised she hadn’t made note in the patient’s record of which tooth was to be extracted. Relying on memory, she wrote tooth 45 in the referral, instead of 44. The wrong tooth was subsequently extracted, causing much embarrassment to both dentists and claims of negligence against them.
  • A young woman presented for the extraction of tooth 35. She completed a ‘medical history form’ in the waiting area on which she disclosed her allergy to codeine. While the dentist asked her a number of questions about her medical history, he did not review the form or ask her about known allergies. He subsequently prescribed an analgesic containing codeine. The woman’s mother contacted the dentist a few days later to advise that her daughter had required hospital treatment for an adverse drug reaction. A letter of demand for compensation followed soon after.

Claims of negligence or misconduct against you

  • A patient telephoned her dentist after hours to report persistent pain and swelling post procedure. The dentist took the call on his mobile phone while he was driving home from work. He clearly recalls advising the patient to come back in the following day if her symptoms had not settled. However, he did not make any record of their conversation.   As the patient did not return the next day, he assumed her symptoms had subsided. Yet the patient was subsequently hospitalised with a systemic infection and later claimed the dentist was negligent in failing to diagnose her condition. She denied that he had told her to return to the practice the following day if her symptoms had not subsided.

Disciplinary action for failing to meet your professional obligations

  • A patient lodged a complaint with AHPRA about the quality of veneers performed on teeth 11 and 21. In investigating the patient’s claim, AHPRA also found the dentist’s record keeping to be seriously deficient. At times he had referred to porcelain fused to metal crowns instead of veneers, and at other times he had recorded the wrong date of the patient’s appointment. Furthermore, while the dentist insists he carefully worked through a process of gaining informed consent to treatment, there was no evidence of this in the clinical record. Therefore, the dentist had the added pressure of responding to further allegations about the appropriateness of his practice.
  • A dentist was asked to provide a copy of her clinical records to AHPRA in response to a complaint made about another dentist. While they had both treated the patient over time, there was no complaint about this dentist. Her records were simply required to help the investigators better understand the patient’s course of treatment. Having provided her records, she was shocked to receive notice from AHPRA advising that her records were now the subject of an investigation. Her record keeping was deemed inadequate in that the hand written notes were illegible, not maintained in chronological order and did not include adequate details of the treatment provided.

Why keep clinical records?

Contrary to popular belief, good record keeping is not simply about protecting yourself from ‘being sued’. It’s more important than that. The primary purpose of clinical records is to ensure the safety and continuity of patient care. That is, to record the patient’s unique journey from start to finish. Carefully recording the sequence of events allows you or someone else, to return to the records at any time to clarify the facts behind your decision making. Even a dentist with a photographic memory can’t remember the circumstances of every patient. Who has a known allergy? What did the OPG taken 4 years ago reveal? What did you advise the patient about that broken endodontic file?

Although good clinical record keeping has always been a requirement for health professionals, the Dental Board of Australia has formalised dentists’ obligations by issuing the Guidelines on dental records. Remember, you must be familiar with the guidelines and disciplinary action can be taken against those who fail to comply.

In addition to the Board’s requirements, good clinical records are essential for fulfilling your obligations to funding providers such as government agencies and private health funds. As dentists well know, compliance audits can be onerous and costly for those who fail to comply.

Finally, good clinical records will assist you in defending a claim of negligence or misconduct against you. The old adage of good records – good defence, poor records – poor defence and no records – no defence is no cliché. If you fail to keep good records, disputes will ultimately boil down to the patient’s word against yours. Conversely, you are much better placed if you can demonstrate that good record keeping is part of your usual practice. Not just for the patient in question, but for all of your patients.

Copies of the Dental Board of Australia’s Guidelines on dental records (2010) can be readily accessed via www.dentalboard.gov.au/Codes-Guidelines/Policies-Codes-Guidelines.

What constitutes clinical records?

Clinical records generally encompass any hard copy or electronic information pertaining to a patient’s care. This includes:

  • Clinical notes, including any diagrams, photographs or consent forms
  • Diagnostic imaging and reports including CAD-CAM restoration files
  • Dental models
  • Reports, referrals and any other correspondence pertaining to the patient that has been exchanged with third parties. This includes Instructions to and communications with laboratories.

General principles for collecting and maintaining clinical records

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What information should be recorded in clinical records?

  • Identifying details of the patient
  • Details of who the patient would like contacted in the unlikely event of a medical emergency
  • Previous and current medical history including any allergies or adverse drug reactions
  • The date of each visit and the identifying details of the practitioner(s) providing the treatment
  • The patient’s presenting problem and any changes in their condition since their last contact with you or your practice
  • Information about the type of assessment, examinations and diagnostic imaging performed
  • Your observations, clinical findings and diagnosis
  • Proposed treatment plans, associated risks and alternatives as discussed with the patient
  • Estimates or quotation of fees
  • The patient’s consent to the agreed treatment and proposed fees
  • All treatment provided and the patient’s response to that treatment. Include the use of any medicines, prostheses or other products. Did the treatment go according to plan? Did the patient respond as you expected?
  • Instrument batch (tracking) control identification, where relevant
  • Instructions to and communications with laboratories
  • Instructions or warnings given to the patient
  • Details of any further exchanges with the patient, or carer, that occurred via telephone, text message or other method
  • Any correspondence with other service providers, or third parties, pertaining to the care of the patient
  • Any other information you feel is relevant to the continuity of the patient’s care

Achieving good clinical records

While it can be tempting to declare that good record keeping is simply too onerous for a busy dentist, many health professionals do manage to achieve it, dentists included. Arguably, success lies in structuring your processes for gathering and recording clinical information in a way that reduces any administrative burden. Work with your Practice Manager to explore ways in which your record keeping processes could be streamlined.

Consider the benefits of using hard copy or electronic templates for recording clinical information. Ensure they are set out in a way that is easy to use.

  • Ensure information gathering follows the sequence of clinical workflow
  • Set out relevant headings in the order a dentist is most likely to use them
  • Insert prompts to remind dentists to record particular information
  • Use colour coding where appropriate, as a visual cue for recording certain information

While it might take some time to set up the practices that work best for you, there are significant benefits to be had, including opportunities for greater business efficiencies.


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