Q. I noticed that the practice manager had been inserting additional treatments into my patient notes. I challenged her about this and was told that it was her role to ensure that all patient notes were annotated to ensure accurate billing. On two occasions now, my patient notes have been amended to include a level one smoking cessation intervention when all I gave the patient was basic advice that really did not constitute a level one intervention. The practice manager is married to the practice owner and I am not sure who I should speak to about this.
All dental records should provide a full, accurate and contemporaneous account of the patient’s treatment. Records can be made by any member of the dental team although the ultimate responsibility for the content of the particular record entry would rest with the treating clinician who saw the patient on that visit or the member of staff who dealt with the patient ( ie. a receptionist cancelling and remaking an appointment).
It follows then that any alteration of the records, if challenged, may raise questions in relation to the honesty and integrity of the person who made the alterations and possibly the original clinician.
On the face of it, the amendments which you mention would appear to have been made in order to generate additional revenue for the practice or at the very least obfuscate the true level of the treatment or advice which was actually provided.
The General Dental Council take any act of dishonesty very seriously. The Standards Guidance urges all registrants to put their patient’s interests before their own and to be trustworthy at all times.
You do not say if the practice manager is a registrant in his or her own right. If he/she is on the dental register, then they should be made aware that an allegation of falsifying patient records could lead to their registration being put at risk.
There are of course occasions when it is necessary to make legitimate additions to a record. This may be as a result of the clinician remembering that particular items of treatment or discussions relating to treatment had not been included into the records at the time of the appointment.
If it is necessary to augment the original record in any way it should be made clear that in the text that an addendum is being made at a time and date other than that when the appointment took place.
Most computer software will not allow retrospective deletion of entries made in a patient’s record. The programme creates a tag on the file showing the time and date of each entry. It may also record which user was logged on when the entry was made.
Clearly this is not the case with handwritten records and care should be taken if alterations are necessary. It is recommended that a line is simply placed through any text so that it can still be read. The alteration should then be clearly shown as being an amendment, initialled with the altering clinician’s name and the date entered when the change was made.
In this case, both the practice manager and practice owner should be made aware of your concerns. It may be useful to justify your reasoning by sharing the information provided above.
The fact that the practice manager and practice owner are married should not affect your desire or ability to practice in an ethical manner. It may also be worth investigating (carefully) if other team members have been similarly affected in which case the issues could be raised informally at a practice meeting.