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How can you meet the new standards for clinical records?

03 November 2020

New guidelines on record-keeping are now in force. Dr Kiran Keshwara, Dentolegal Consultant at Dental Protection, looks at what has changed and the new resources available to dental practitioners

On 1 October 2020, the Dental Board of Australia (the Board) retired the four-page Guidelines on dental records, as it felt that the Code of conduct contained adequate guidance to dental practitioners about record keeping. In addition to the guidance in the Code of conduct, the Board has developed a factsheet and a self-reflective tool to help clinicians understand and comply with their obligations.

What does the factsheet explain?

The factsheet sets out the expectations of clinicians and directs them to the relevant documentation.

A practitioner is expected to:

  • Practise in accordance with the Board’s regulatory standards, codes and guidelines, including:
    • The Code of conduct, which contains information on confidentiality, privacy and informed consent
    • Ongoing CPD courses on record keeping
    • Ensuring appropriate professional indemnity insurance is in place
  • Comply with:
    • The relevant state and territory legislative requirements on health records
    • Relevant privacy requirement – this includes the Privacy Act 1988, which details the use, disclosure and release of a patient’s personal information and details
  • Understand:
    • What constitutes a health record
    • Your responsibilities when making a health record
    • What should be recorded in the health record

What is the Code of conduct?

This is the main document containing the standards that all practitioners are held to and was developed in 2014. Along with Section 2 (Providing good care) and Section 3 (Working with patients or clients), Section 8.4 of the Code of conduct specifically details expectations of clinicians concerning dental records. It states:

Good practice involves:

  1. keeping accurate, up-to-date, factual, objective and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients or clients, medication and other management in a form that can be understood by other health practitioners
  2. ensuring that records are held securely and are not subject to unauthorised access, regardless of whether they are held electronically and/or in hard copy
  3. ensuring that records show respect for patients or clients and do not include demeaning or derogatory remarks
  4. ensuring that records are sufficient to facilitate continuity of care
  5. making records at the time of events or as soon as possible afterwards
  6. recognising the right of patients or clients to access information contained in their health records and facilitating that access, and
  7. promptly facilitating the transfer of health information when requested by patients or clients.

Self-reflective tool – a must for practitioners

This is the newest document made available to practitioners and should definitely be reviewed. The self-reflective tool is a series of questions and statements that encourages clinicians to think about the different aspects of the records created, which will further help clinicians identify any gaps in their knowledge, skills and systems. This information can then be used to improve the record keeping process, encourage discussion amongst clinicians and highlight areas where further record keeping CPD is required.

It is important to remember that the self-reflective tool is not a comprehensive list of the detail that should be included in patient records. It should be used as a starting point to reflect on and consider the records, and for understanding the type of information that should be included.

The self-reflective tool encourages clinicians to complete random audits of the records created to check and remind them of important aspects of the dental records including:

  • Ensuring that records are accurate and up to date
  • Evidence that patients were fully informed of their options and these options were explored in detail, including costs and personal circumstances
  • Diagnostic data (eg dental charting, temporomandibular joint examination findings, pulp sensibility tests and periodontal probing)
  • Diagnoses
  • Medication prescribed, including information on dose, quantity and instructions provided
  • Continuity of care

The Code of conduct, which is the main documentation for all dental practitioners, and the new factsheet and self-reflective tool, make it very clear that the Board expects clinicians to create records that are detailed and accurate, which can be used to facilitate ongoing patient care. The Board also highlights the need to be aware of the relevant legislation for the state that clinicians work in, and to undertake ongoing CPD and audits of their clinical records.

Further resources

RiskBites – Dental Protection’s podcast series, How to document risks and warnings in your dental records

Recorded webinar – What does the new standard on record keeping mean for me?

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