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Record keeping challenges in the era of COVID-19

20 November 2020


By Dr Louise Eggleton, Dentolegal Consultant

Over the course of this year the world has dramatically changed with the emergence of COVID-19.

Dental professionals were already accustomed to managing the challenges of viral transmissions as part of our everyday routine. However, with the spread of a new virus and a world pandemic, the practice of dentistry has been severely impacted. Many dental clinics have had to endure closure or suspend routine care in order to help reduce the transmission of COVID-19. As dental clinics adapt to new ways in which treatments are provided, while facing unfamiliar and unexpected challenges from patients, has the way we maintain our treatment records changed too?

Record keeping standards are unchanged

Certainly, even persevering through a world pandemic and managing the restrictions on dental care does not amend or reduce the requirement to follow the professional standards on record keeping upheld by Dental Councils.

Where patients are faced with the prospect of limited care, naturally it can be anticipated some individuals will be disappointed or unhappy that they are not able to access the full range of services dental clinics would have usually provided. In the event of a complaint, your record becomes the key evidence you may need to rely on to demonstrate the detail of your discussions with the patient, that their request was managed appropriately and in accordance with any current protocols or restrictions in place at that time.

So, what kind of detail are we talking about? Well, as for all interactions with a patient, the reason the patient has contacted the practice needs to be recorded. This may include an enquiry about routine care provision or perhaps a request for urgent emergency care. Due to the changing situation of COVID-19 transmission, which is unique to each individual country, the dentist should also record the clinic’s most up to date protocol based upon government guidance. This should include whether the dentist is able to provide an appointment to the patient, or if any other restrictions are currently in place to prevent this.

You will need to include the key issues that may have restricted the availability of routine care in your records:

  • You may have been working remotely as the dental clinic was required to close and you did not have access to the patient record, or the patient was previously unknown to you, making diagnosis more challenging.
  • You may have been limited by the service you were able to provide by complying with specific government or local guidance.
  • Your enquiries into the patient’s health as part of establishing whether the patient, or members of their household, may be suffering any potential COVID-19 related symptoms.
  • The dental symptoms the patient may be experiencing and whether the clinic has capacity to provide the patient with an appointment, or if a referral to an alternative dental care centre may be necessary.
  • Any digital information provided by the patient, including your discussions and clinical advice provided.
  • Effectively managing patient expectations if restrictions remain in place that prevent the provision of full dental services at the clinic. Patients may feel their situation is an emergency, even though it does not meet the threshold set out in local guidance. By recording the specific nature of a patient’s clinical situation and advice you provided, it will be of great assistance in defending your position in the future, should this become necessary.

Recording advice to patients – including social distancing

In reopening dental clinics for those who are continuing to work under specific restrictions, there will have been a significant change in the way treatment is provided. This includes new practice protocols such as maintaining a degree of social distancing. This may mean the patient is asked to remain outside the clinic until a member of the dental team invites them in, to begin their safe movement through the practice.    

It is very helpful if a patient is advised of any changes the clinic has implemented, in addition to their usual treatment experience, prior to the appointment. Reassurances can be made regarding changes in clinic protocols that have been put in place to ensure the safety of all staff and patients. This will also help manage any unrealistic expectations a patient may have if you are unable to provide certain types of treatments or require additional equipment, such as the use of dental rubber dam or introducing mouth-washing regimes. Dental Protection advises you to record all these interactions with the patient, to provide a clear picture that they have all the necessary information about clinic protocols and what treatments are currently permitted.

Of course, during the treatment appointment, the usual vital information should be recorded in the clinical notes. These include:

  • All PPE worn by the dentist, dental care professional and patient
  • Thorough clinical history
  • Medical history
  • Whether the situation can be managed with advice, analgesia or antimicrobials and why (should you be unable to provide an appointment to the patient at that time)
  • Clinical assessment and any special tests
  • Radiographic reports
  • Diagnosis
  • Treatment options, including a referral to a specialist colleague
  • Agreed treatment plan and estimates
  • Additional information provided to the patient in respect of their specific treatment – for example, the availability of appointment times and if any delays in treatment provision may be experienced
  • Consent from the patient should it become necessary to share or discuss their information with another practitioner – for example, you need to contact the patient’s regular dentist to obtain more information, or require a second opinion in order to be able to make a decision regarding an urgent care request.

If there has been an extreme circumstance and you have been unable to comply with the current local guidance when you have been providing care, then your records must fully demonstrate your reasons to justify your decision. Any deviation from the local guidelines or government protocols at the time may well attract attention, and you must be able to ensure you can robustly defend your decisions by evidence in the treatment records.

Digital communications

It has been necessary for patients to communicate digitally where dental clinics were required to close or reduce the number of patients to whom they were able to offer an appointment. There has been a huge increase in the practice of teledentistry, video conference appointments, emails or use of digital photographs to assist with the dentist’s assessment and diagnostic process.

Patients have provided images of their mouth, face and even medications. It is important to remember any type of digital information and verbal information provided by the patient is also part of the clinical record and should be recorded as such. You will need to think about how this digital information is stored with a view to the requirements of your Dental Council, ensuring patient confidentiality is maintained and meets national regulation. Remember, any digital communication that is a part of the dental record is expected to be provided to the patient if they request a copy of their records in the future.

Any information that may have been recorded while working away from the clinic will need to be scanned or uploaded on to the practice IT system as soon as possible.

The ongoing importance of clinical records

While we all begin to resume a kind of ‘usual’ practice, the worldwide situation regarding COVID-19 virus transmission continues to evolve and change. We are obviously all acutely aware COVID-19 will continue to affect our lives on a personal and professional basis for some time to come, and the pace of dentistry provision will be required to adapt to varying Government alert levels.

Therefore, it is paramount to ensure all communications we have with our patients, under whatever those current circumstances may be, are appropriately recorded. Dentists need to continue to maintain high quality treatment records to reflect patients’ experiences, what treatment was provided, and how this may have been affected by the restrictions in practice based upon local guidance.

Please note: Dental Protection does not maintain this article and therefore the advice given may be incorrect or out of date, and may not constitute a definitive or complete statement of the legal, regulatory and/or clinical environment. MPS accepts no responsibility for the accuracy or completeness of the advice given, in particular where the legal, regulatory and/or clinical environment has changed. Articles are not intended to constitute advice in any specific situation, and if you are a member you should contact Dental Protection for tailored advice. All implied warranties and conditions are excluded, to the maximum extent permitted by law.