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Co-operation & compliance

27 August 2014
There are many examples in clinical dentistry of treatment which is largely dependent upon the level of co-operation from the patient, and/or the degree to which the patient follows the advice and recommendations of the clinical team.

The most obvious example of this is whether or not the patient attends appointments which are booked for them, and the lengths to which reception staff must go to accommodate the patient’s demands in respect of the days and times at which they are available to attend appointments.

This is frequently seen when providing orthodontic treatment for children whose parent(s) need to bring them along for appointments. In effect, you need at least two people to be available simultaneously - perhaps balancing the parent’s work commitments, or conflicting family responsibilities, and the child’s schooling demands.

Many forms of orthodontics require high levels of co-operation in terms of wearing appliances and/or headgear, changing elastics or adjusting other elements of the appliance. In periodontics and implant dentistry, the patient’s home care is an essential part of the treatment. Wearing occlusal splints or ‘nightguards’ can be pivotal to the success of restorative/prosthodontic treatment.

When treating or preventing caries or tooth surface loss through erosion, compliance with dietary recommendations or the avoidance of certain kinds of drinks will have a direct effect upon the likely outcome of treatment.

In the light of all the above, it is surprising how often the difficulties encountered by a clinician or his/her team, in any of the above respects, are not sufficiently reflected in the patient’s clinical notes.

In particular, although there may well be a brief entry to the effect that a patient is not wearing an appliance, there may not be a clear confirmation that the patient (and/or parents) were left in no doubt as to the likely consequences of non-co-operation on treatment outcomes.

In terms of patient attendance, there should be a reliable mechanism whereby all appointments booked, and all contacts with the practice (including details of telephone calls) are recorded in the notes. Reception staff should be encouraged to record relevant facts regarding a patient’s availability (or unavailability) for appointments. They should also appreciate the importance of recording the appointments that the patient cancels, or fails to attend. Of particular relevance here are appointments which are cancelled by the patient at the last minute, or where the patient arrives so late that it is not possible to see them that day. All of this information, if carefully recorded, helps to build up a comprehensive picture of the difficulty faced by a clinician in completing a patient’s treatment.

Many examples of this are seen in orthodontics, where a complaint or claim may be made regarding a lack of progress, or the fact that an orthodontic situation seems to be worsening as treatment proceeds. The dentist will often describe a situation where appointments were missed, appliances not worn or oral hygiene was not maintained, while the parents were becoming increasingly angry at the length of the treatment.

In such cases, full and detailed records can be invaluable in order to demonstrate what was really happening. Ideally, such records can be augmented by a letter having been sent to the parents at an appropriate moment, to emphasise the reasons for the lack of progress and the need for co-operation from all concerned.

This aspect of treatment is one where nursing, reception, and administrative staff can do a lot to add substance to the clinical notes, if they are empowered and encouraged to do so.

Audit Exercise A - Quantitative Review

At a meeting which includes clinicians (dentist/hygienist/therapist), dental nurses and reception staff, compile a list of patients who:

  • Have a poor attendance history
  • Do not follow clinical advice and recommendations
  • Do not co-operate with treatment

Review the clinical records of one of the above groups of patients, scoring them against a pre-agreed scale. For example:

  1. Failures to attend booked appointments are clearly recorded in the notes:
    4 Always
    3 Usually
    2 Sometimes
    1 Rarely
    0 Never
  2. The length of the wasted appointment time is recorded:
    4 Always
    3 Usually
    2 Sometimes
    1 Rarely
    0 Never
  3. There is a dated entry in the clinical records confirming that the need for patient co-operation and compliance was stressed to the patient/parents:
    4 Always
    3 Usually
    2 Sometimes
    1 Rarely
    0 Never

You can extend/vary the above criteria, according to the type of procedures you are carrying out.

To convert these results into a percentage measure that will allow you to compare these baseline results with subsequent performance, you could allocate a score from to 4 (always = 4, never = 0). Because your sample size might vary from one review point to another, you might find it more convenient to convert your results into a percentage (%) score.

In the above example, you might decide upon 5 questions giving you a total possible score of 20 (5 x 4). A score of 12/20 becomes 60%.

Audit Exercise B - Qualitative Review

Use a similar system to examine the quality of the records you have kept. For example:

  • Is it clear who stressed the importance of co-operation and compliance (and when)?
  • Is it clear who else was present (e.g. a child’s mother)?
  • Do the records demonstrate that the patient/parents were told why co-operation/compliance was required?
  • Do the records demonstrate that the patient/parents were told what might happen (or not happen) in the absence of the required levels of co-operation/compliance?
  • Do the records confirm that the patient was given a specific, measurable level of co-operation/ compliance to aim for? Do the records make it clear what follow-up action/ reinforcement occurred, when, and from whom?
  • Do the records include any copies of any correspondence sent at key moments in the treatment?
  • Do the records include any independent evidence that the patient’s co-operation/compliance was less than ideal?

Examples might be exchanges of correspondence with dentists to/from whom the patient has been referred.