Auto-templates are often used by dental practitioners to increase the efficiency of their dental records. However, they can lead to inaccuracies. Dr Annalene Weston, Dentolegal Consultant at Dental Protection, considers the consequences.
Mrs C attended Dr D with a tooth ache in her 37. She reported that the pain was continuous, keeping her awake at night, and unresponsive to pain medications. Dr D assessed the tooth and found it to be unrestored and caries free, but with a distal pocket of 8mm and grade 1 mobility. The periapical radiograph was unremarkable, and Dr D offered Mrs C several options including debridement of the pocket only and referral to a specialist for an assessment; on the day, Mrs C opted to try the debridement. However, she failed to attend the scheduled review appointment, leading Dr D to believe that all was not well.
Regretfully, Mrs C attended approximately two weeks after the review was planned with exquisite pain associated with tooth 37. Dr D retook all of the diagnostic tests, and a distal crack was identified. Dr D again offered referral, and also extirpation of the tooth as an option. Mrs C preferred an extraction as, simply put, she had had enough.
The extraction did not go well. Dr D luxated the already mobile tooth, getting some reasonable movement, but on the application of the forceps the tooth decoronated. Dr D spent a fruitless 40 minutes attempting to remove the remaining roots piecemeal, until eventually admitting defeat. Mrs C, tired and overwhelmed, preferred to not proceed with a surgical approach on that day, and refused a referral. She wanted to go home.
Dr D did not enter notes immediately, intending to come back later in the day, as he was now running very late. At the end of what had been an arduous day, it slipped his mind, which meant that the auto-template note only was entered as follows:
311: 2 x 2% lignospan. Simple exo. Luxators and forceps. HAEM. POIG.
Not only did this not reflect the truth of the extraction, but also critical discussions with Mrs C were missing.
Listed, in no particular order of importance, the records are missing:
- The reason for attendance
- The patient’s symptoms
- The special tests undertaken
- The diagnosis
- The treatment options given, including the risks and warnings of each
- The mode of administration of the local anaesthetic
- The fact the tooth fractured when the forceps were applied
- The fact that the roots were chipping and extracted piecemeal
- The fact the roots were retained, and that Mrs C was advised of this
- The fact Mrs C declined a surgical approach
- The offer of a referral both before the commencement of the extraction, and after the retained roots could not be removed.
Mrs C suffered with pain after the extraction and went to see another dentist. They took a PA and uncovered the retained roots, a fact that Mrs C had either forgotten in the distress of the appointment, or perhaps never truly understood at the time. This discovery, and the new dentist’s reaction to Mrs C’s apparent ignorance to the facts, prompted her to complain to the regulator.
On this occasion, the regulator chose to meet with Dr D to talk through their concerns. They were clear with him that the failed extraction in itself was not the reason they were considering disciplinary action, but rather the seeming inaccuracy of his records. In the absence of accurate notes reflecting what actually happened, Dr D could not defend himself against Mrs C’s allegations that he had not assessed her properly, and that he had not told her of the retained roots, nor offered to refer her to a specialist colleague for management.
Pleasingly, the regulator accepted that Dr D had undertaken appropriate pre and postoperative steps, and that his management of Mrs C was appropriate – he just couldn’t prove it. They counselled him regarding accurate record keeping in the future.
Learning points
- While they can increase our efficiency, auto-templated records must be modified for each patient to accurately reflect the unique circumstances of their treatment.
- Inaccurate or inadequate records do not enable continuity of patient care, as the next practitioner is not party to what really happened on the day.
- Inaccurate records impact on our ability to defend ourselves against allegations.
- Inaccurate records reflect poorly on our professionalism as we are breaching the standard required by our regulator.
- You can check how your records stack up using this self-reflective tool.