Dr Joe Ingham, dentolegal consultant at Dental Protection, looks at the vital role of record keeping in safeguarding your practice
Legible notes must be kept primarily to assist the patient when receiving treatment. But, secondly, should there be any future litigation against your practice the notes will form the basis of your defence.
Notes are a reflection of the quality of care given so get into the habit of writing comprehensive and contemporaneous notes.
Adequate records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory. A colleague should be able to carry on where you left off.
• Always date and sign your notes, whether written or on computer. Don’t change them. If you realise later that they are factually inaccurate, add an amendment. Any correction must be clearly shown as an alteration, complete with the date the amendment was made, and your name.
• Making good notes should become habitual.
• Document the history of complaint, clinical and radiographic assessment including special tests, diagnosis, discussions of treatment options and their risks and benefits, treatment plan with estimated costs.
• Dental records can contain a wide range of information, including dental charting, treatment plans, radiographs, clinical photographs, scans, referral letters, laboratory documents and study models.
• Do not write offensive or gratuitous comments – eg racist, sexist or ageist remarks. Only include things that are relevant to the health record.
Dr P sees Mrs G for a new patient examination when she attends complaining of a fractured lower left first molar LL6. She takes a comprehensive history, and does a complete examination including radiographs.
Mrs G has a severe gag reflex and is not able tolerate intra oral radiographs and as a result the apex of the LL6 is missed from the periapical radiograph.
Dr P arranges for Mrs G to return for treatment at the LL6 with a view to retaking the periapical at the next visit, since Mrs G is by now feeling quite anxious. Dr P, now running ten minutes late, fails to note the issues encountered at this visit.
Mrs G does not return for treatment for another two months. At this emergency visit, Dr P repairs LL6 with a filling and advises that the tooth may need a crown. He does not review the radiographs as he had intended to do so and therefore failed to retake the periapical radiograph.
Mrs G develops pain and swelling two weeks after this treatment and decides to see a new dentist, who takes a radiograph of LL6 and advises root canal treatment. Mrs G writes a letter of complaint and it is only when Dr P asks Dental Protection for assistance that it becomes evident from the records that he failed to record the issues with obtaining a periapical radiograph of LL6 and failed to retake it when Mrs G returned for treatment, and as a result did not assess the apical status of LL6 before restoring it.
This was a vulnerability when responding to the complaint and resulted in Dr P offering remedial treatment costs for the root canal treatment.