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Protect yourself and your patients with record keeping

25 April 2018
Dental Protection solicitor Julia Bryden talks about her experience of complaints and how practitioners can protect themselves with better record keeping

Read this article to:
  • Understand how accurate dental records can help protect you when faced with a complaint
  • Learn what needs to be included in dental records
  • Discover top tips to improve record keeping
Regulatory challenges, complaints and clinical negligence claims are an occupational hazard in today’s climate. Sadly, complaints can still occur even when quality care has been provided.

While our highly experienced team of dentolegal advisers can assist you through these challenging times, I would like to discuss some of the steps you can take in advance to protect yourself against challenge.

The importance of accurate dental records cannot be overstated. This is because the content and quality of dental records will determine whether a complaint can be successfully defended. Unfortunately, a number of claims have to be settled due to a lack of detail in the clinical records, and many dental practitioners have fallen foul of their regulator for the same reason.

Contemporaneous records will, however, support and supplement your recollection of the treatment and advice provided. They will also corroborate your version of events. This is invaluable in defending yourself, as we find there is often a conflict of evidence: in other words, it is your word against the patient’s.

We recognise that members are busy and face huge time pressures, but here are some practical tips to help keep the lawyers at bay.

What should be included in dental records?
  • Details of the patient history, the nature of symptoms, and exacerbating factors.
  • Objective examination findings, including the absence of significant signs.
  • Differential diagnosis.
  • Any other opinions regarding diagnosis.
  • Details of any investigations required, for example, vitality tests, x-rays, and models.
  • Details of any treatment carried out, for example, anaesthetic usage and materials used.
  • Follow up arrangements. Is a review or a referral required?
  • The specific issues discussed with the patient, such as recognised risks and complications associated with the procedure in question.
  • Warnings about the importance of good oral hygiene.
Paper records should include your initials, signature and the date on which the record was made.

If you need to alter or remove an incorrect entry in paper records, simply cross through the wording and mark this with your initials, the date and the reason for the alteration. The original entry should still be legible. This is particularly important to ensure your credibility is not questioned if the case ends up in court.

If you need to make a non-contemporaneous entry, for example, if you recollect a conversation with a patient, you should ensure that the date of that entry is clearly recorded.

Golden rules
Abbreviations should only be used when their meaning is universally agreed and easily understood by your colleagues.

Every patient contact is recorded
This includes each interaction with a patient (for example, telephone calls) even if no clinical advice is given.

The absence of significant symptoms/signs
It is best practice to record a negative, to provide objective evidence of your underlying thought process.

Always record a diagnosis, even if provisional. This provides further evidence of your clinical reasoning. Making an incorrect diagnosis is not necessarily negligent if a reasonable logical explanation can be given.

Follow-up advice
The patient and dentist can have very different recollections of the follow-up advice provided, so it is always best to document this in clear terms.

Consent discussions
The vast majority of claims notified to Dental Protection contain allegations in relation to consent. In our experience, this is often used to get the weakest claims over the line, so it is vital to ensure those discussions are well documented. Limitations of treatment can be important in many areas of dentistry, such as advanced restorative treatment and orthodontics, and these issues should be explained and documented.

Discussions around any alternative treatment options should also be documented, along with advice provided in relation to any future treatment requirements. It is also crucial to fully explain any costs involved and ensure the patient is in agreement. Patient expectations can often be unrealistic, so you should be satisfied that the potential limitations are fully understood.

Whilst it may not be possible to avoid a complaint being made, even if gold standard treatment was provided, following the above advice should increase your prospects of a successful defence. In the event of receiving notification of a complaint, then please contact our team on 1800 444 542 or [email protected]
Related content
Further information about record keeping can be found on our e-learning programme Prism, including a recording of our recent webinar Recording your way out of trouble.

You can also listen to our podcast series for further guidance and advice.

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DPL Australia Pty Ltd (“DPLA”) is registered in Australia with ABN 24 092 695 933. Dental Protection Limited (“DPL”) is registered in England (No. 2374160) and along with DPLA is part of the Medical Protection Society Limited (“MPS”) group of companies. MPS is registered in England (No. 36142). Both DPL and MPS have their registered office at Level 19, The Shard, 32 London Bridge Street, London, SE1 9SG. DPL serves and supports the dental members of MPS. All the benefits of MPS membership are discretionary, as set out in MPS’s Memorandum and Articles of Association.
“Dental Protection member” in Australia means a non-indemnity dental member of MPS. Dental Protection members may hold membership independently or in conjunction with membership of the Australian Dental Association (W.A. Branch) Inc. (“ADAWA”).
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Dental Protection members who are also ADAWA members need to apply for, and where applicable maintain, an individual Dental Indemnity Policy underwritten by MDANI, which is available in accordance with the provisions of ADAWA membership.
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