This situation arose during my first year out after graduation...
I was working hard on a busy Saturday, seeing patient after patient alone in the clinic, trying hard to stay on time throughout the day. I was already running late, and to make it worse, an emergency patient arrived in pain without an appointment and no appointment times available in my book. I had to see him though. I couldn’t just leave someone in pain.
After talking to the patient about his symptoms and performing a limited examination, I took x-rays, performed vitality testis and made a diagnosis of irreversible pulpitis. We talked through the available options and the patient chose to proceed with a root canal treatment as he did not want to lose the tooth. I performed an extirpation on the suspect tooth and, after a hard, long day, I went on two weeks' leave, without any idea of what lay ahead.
When I came back from my leave, I was quite surprised to find a letter from HCCC (I didn’t even know what the acronym stood for, back then!) lying on my table. When I opened up the letter I realised the emergency patient that I treated on that Saturday had submitted a complaint about me saying that I treated the wrong tooth.
I was really distressed to have received such a letter. No one had ever complained about me before so I wasn’t really sure what to do. I thought I would start by looking at my clinical records and x-rays, and to my horror, I realised there were no notes written for this patient.
At this stage of my career, especially on such a busy Saturday when I was pushed for time, I had written up notes in one single batch, either at lunch time or at the end of the day. I must have forgotten to do any notes for this patient on that day.
This is when I called DPL for help. When I look back, this was a time in my life when I was already quite stressed. All those articles that you read in dental magazines about cases like this, but you think it will never happen to you.
No notes meant I had nothing to back up my version of events or protect myself with. No protection from the patient’s complaint that had come through the door!
It took close to a year before the complaint was finally resolved. There were multiple letters, emails and correspondence between HCCC and myself with DPL assisting me every step of the way, but most of all there were long, restless waiting times.
DPL has been incredibly supportive, comforting and informative, and helped me to prepare well for the necessary submissions. The patient was satisfied, however there was one more step I now realised - I had to attend a meeting with the Dental Board to talk through what had happened; most critically, my lack of records. I was terrified, and I couldn’t believe it when someone from DPL also came with me to support me through the most frightening two hours of my life.
To my surprise, this Board meeting was incredibly constructive and I found that it genuinely helped me to adopt a practical protocol to ensure that a similar event could not happen again.
I now do the notes right after each patient, and schedule my book to give me enough time, both for treating patients so I don’t feel so pressured, and for the necessary record keeping. I realise that it’s only the detailed clinical notes that can help protect me when an unexpected complaint arises. Although I had really let myself down – in the past – that was now behind me.
The Dentolegal Adviser's Perspective
Dr Annalene Weston
Dr M was not alone in finding herself without the time she needed to write records. It is all too easy to get “pushed” through a day and find yourself scrabbling to get your records written long after they ideally would have been done.
However, Dr M is quite right to comment that without contemporaneous records, she had no defence against the patient’s (inaccurate) allegations, and further, her very standard of practise and professionalism was called into question due to her failure to make records. This was an unpleasant situation for any caring health professional.
Every Dental Board has a standard on record keeping, and Dental Protection would urge you to take the time to review this. Write your records straight after the appointment, and remember that it is those conversations, unique to each patient, that will help you remember what you really discussed on the day.
It’s perfectly acceptable to get your nurse to write your notes, but you alone are responsible for their content and detail so it is critical that you read them immediately after the appointment, and add to them then if required. Any later amendments must be appropriately post-dated.
It is a fantastic outcome to know that Dr M found her meeting with the Dental Board so constructive, but it is a very stressful way for her to have learnt this lesson, that can always be avoided by ensuring that the patient’s records are always written up at the time of their appointment.