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Follow-up arrangements


27 August 2014
There are many moments in clinical dentistry when the most crucial aspect of case management is not what you do, but what arrangements you make to monitor the effectiveness of what you do.

Whenever an adverse outcome arises – particularly when it is of a serious nature – it will often be asked whether there was anything more (or anything different) that could have been done, which might have mitigated the adverse outcome, or perhaps avoided it altogether. Some examples of this include:

  • Medication – Following up the progress of an infection after the prescription of antibiotics, or the status of other conditions for which you have prescribed medication.
  • Postoperative complications – For example, checking the satisfactory resolution of postoperative pain, swelling or bleeding.
  • Healing – Checking the progress/healing of a wound (such as an extraction site) or an acute oral lesion of some kind. Assessing the integration of an implant fixture would be another example
  • Chronic conditions – Monitoring the progress of periodontal disease at appropriate intervals, or an oral lesion of unusual appearance. This is particularly important if potentially serious pathology (for example, carcinoma) is suspected or forms part of a differential diagnosis.
  • Comfort and function – Where a patient has complained of discomfort, or some kind of functional difficulty (for example, with biting, eating, chewing or speech).
  • Growth and development – When treating the younger patient, it is often necessary to wait for further growth and development and/or the exfoliation of primary teeth.
  • Referrals – There can sometimes be an ill-defined relationship between two professional colleagues who are involved in the referral of a patient to and from the other. Confusion can arise as to which of the two clinicians is responsible for some particular aspect of the patient’s overall care, especially if the patient is notionally under the care of both clinicians at the same time. As a result, these aspects of the patient’s care can sometimes disappear unnoticed down the ‘crack’ between the two clinicians.
  • Routine review appointments – The appropriate recall interval is not the same for all patients. Patients should be given some guidance in this respect rather than being left to guess what an appropriate interval might be for their needs. Patients who are felt to be at greater risk (for whatever reason) might need to be reviewed at more frequent intervals. Relapse – Some kinds of treatment – such as orthodontic or orthognathic treatment, or tooth whitening/bleaching – might in some circumstances have a greater tendency to cause relapse than other forms of dental treatment.
  • Systemic and transient conditions – Some oral conditions can be affected by pregnancy, medication or other treatment which has been given for entirely different (perhaps medical) conditions. In these situations it may be sensible to wait until the effect of this transient factor has ceased, in order to form a better assessment of the underlying condition.
Communication

Think about how clearly you communicate the need for a situation to be followed up, and why, and how well you have explained the potential consequences of not doing so. Patients will sometimes argue, after a condition has deteriorated unnecessarily, that although a suitable review interval was loosely suggested or discussed, there had been little or no attempt to convey any sense of urgency or importance in relation to such follow-ups.

If a patient has been referred to an oral medicine/oral pathology specialist for a diagnosis of a suspicious oral lesion, don’t just assume that they turned up for the appointment and wait for a report from the specialist. This is one occasion when ‘no news’ may not be ‘good news’ at all.

Alerts
Some of the above situations clearly need to be followed up more proactively than others. Some have life-threatening consequences, whereas others are more of a courtesy in terms of professional patient care. The more serious types of follow-up clearly need to be ‘diarised’ or flagged-up in some way so that they are not overlooked. This is important so that (for example) support staff fully appreciate the implications of a patient subsequently calling to cancel or postpone an important appointment that has been made for this purpose.

Records

The clinical records should always confirm the arrangements that have been discussed and agreed with a patient in relation to follow-up. Try to get into the habit of checking that this has been done, and involve any dental nurse with whom you work in this process, to make sure that you don’t overlook it. Is the patient going to contact you, or are you going to contact the patient? If the latter, have you checked that the contact details you are holding remain correct and up-to-date?

Audit

Review a sample of record cards for patients where some kind of follow-up arrangements needed to be made, and measure in what proportion of these cases your records:

  1. Clearly demonstrate that an appropriate recommended follow-up appointment was made or suggested.
  2. Clearly demonstrate the suggested interval for such follow-up.
  3. Clearly demonstrate that the need for follow-up was explained to the patient, along with any potential risks of not doing so.

Repeat the audit exercise after making any necessary changes to your internal systems and processes.

Added benefit

Even when there are no serious adverse consequences of failing to make any specific follow-up arrangements, following up a patient is still a tangible demonstration of a clinician’s care, concern and professionalism. The reverse can also be true, and a failure to offer any kind of follow-up could be interpreted (at best) as disinterest or an uncaring attitude or (at worst) a breach of your duty of care. An unexpected telephone call to check on a patient after a treatment complication has arisen, or even after some kind of dissatisfaction has been expressed, can strengthen the dentist/patient relationship, create (or restore) confidence, and not least can give an opportunity to resolve any outstanding issues. Every action you or any staff members take by way of follow up should always be carefully recorded in the clinical notes because they provide an important demonstration of the overall quality of care that was provided to the patient.

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