In reviewing clinical records in cases of complaints or claims against members, it often becomes apparent that the use of autotext and pre-set templates does not always provide an accurate clinical record.
Computerised record keeping is becoming more and more popular and may now be considered normal practice. Clinical and practice management software is marketed as improving efficiency for the business of dentistry. Most dental software programmes provide a recording platform with autotext templates to help the busy practitioner record clinical records.
The Dental Council imposes a professional obligation that practitioners must keep accurate and up-to-date records for all patients. By doing so we are arming ourselves with one of the best risk management tools. In a busy clinical practice it can be challenging to ensure our record keeping is as detailed as it should be and we look to efficient and time saving methods such as pre-set templates which have been designed to act as both an aide memoire and a recording tool.
However, in reviewing clinical records in cases of complaints or claims against members, it often becomes apparent that the use of these templates does not always provide an accurate clinical record. They may not reflect particular and specific discussions that took place with individual patients. The use of autotext can call into question the veracity of records and whether the procedures listed have actually been undertaken or whether a box has simply been ticked as a routine.
Dental Protection has seen records where hygienists have recorded identical clinical procedure notes at each appointment for the same and different patients; we have seen BPE’s recorded in patients who are edentulous and also records of consent being obtained, when there is no clear record of the discussions between the patient and the clinician. The patient is entitled under data protection regulations to have a copy of their clinical records, and if the patient was to read the record, it needs to accurately reflect any discussions that have taken place. If autotext has been used inappropriately or incorrectly the dentist’s professionalism and competence may be questioned.
Detailed, accurate and contemporaneous records are imperative to limit a member’s vulnerability in defending any allegations. The dental team must consider this when using clinical record templates.