Maintaining clear, coherent and effective notes might seem straightforward, but each case is unique and even the most experienced dentists can come up against dentolegal pitfalls
Even for dentists that are relatively proficient at writing up the patient’s record and have developed their own style, it’s easy to have specific concerns, like: “How do I ensure the patient has fully understood and provided valid consent?” or 'How comprehensive would my notes need to be to stand up to a complaint or claim?".
These areas of ambiguity can make all the difference in the event of a claim, so understanding the nuances of note taking is highly important.
THREE TOP TIPS FOR NOTE KEEPING
- Keep full and thorough notes
Try to keep all records electronically as much as possible. For practices with a hybrid system of computer and paper records, try and discourage dental colleagues from leaving post-it reminders or paper notes hanging around without direct communication as to what these are. Ensuring there is an audit trail for all your notes not only safeguards you and your practice, it makes for the best possible quality of treatment for your patients, too. Make sure that you check that your backup system works regularly.
- Use templates
Make use of any templates that are stored in your practice’s system. These are usually very comprehensive and include everything you might need to write in dental records, so following them makes the whole process a little more systematic and ensures you don’t forget anything.
- Where it is not possible to use electronic records, hand written records must be legible and clearly signed and dated. Any alterations to the record must be clearly identifiable (by marking the additional entry with the date it has been made), rather than by inserting it on the day of treatment. Any attempt to ‘improve’ the record is misleading and in some jurisdictions could be
- Avoid ambiguity
Avoid ambiguity or acronyms where there is any reasonable doubt as to their meaning – misinterpretation could lead to problems later down the line. If you prefer to use a lot of acronyms, consider establishing a key for your whole practice to refer to.
For more information on record keeping, Dental Protection offers Clinical Audit Tools
for you to measure the effectiveness of your practice’s risk management.