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Good records, good practice

19 February 2018
In busy clinical practice, it’s easy for record-keeping to be viewed as an administrative burden, and drop down the priority list. Dental Protection is delivering a webinar for dentists across South Africa, which will show why good records mean good practice.

Some areas of record-keeping continue to present difficulties for dentists. Many of us are aware that our records could be improved, a point brought sharply into focus when we are asked to explain our assessment and management of a patient a long time after the examination and treatment took place.

This, in turn, poses a challenge for Dental Protection when we are responding to complaints or claims against dentists. The quality of record-keeping is often the difference between a positive or negative outcome in a case, as demonstrated in this scenario:

Case study

A recently qualified dentist decided to remove a maxillary first molar under local anaesthetic and, having explained the procedure to the patient, obtained her consent to proceed with the extraction. The case turned out to be more difficult than had been anticipated, even having the benefit of a good pre-operative radiograph.

Unfortunately the dentist displaced the mesio-buccal root into the maxillary antrum after the tooth had been sectioned, creating an oro-antral fistula. As soon as the dentist realised what had happened, he explained the situation to the patient and, while she was still in the chair, sought advice from the local maxillofacial surgeon on the telephone.

The surgeon advised a primary closure for the socket and the prescription of an appropriate antibiotic, along with the usual antral regime. All these discussions were recorded in the notes.

The dentist asked a senior dentist in the practice to close the socket. The patient was then discharged with the appropriate prescriptions and instructions. A referral letter including the radiograph was immediately written and sent to the maxillofacial surgeon.
Complaint after follow-up

The patient was followed up, in due course, at the local hospital and after several weeks of continued symptoms, she eventually recovered. The dentist was shocked to receive a complaint from the patient, alleging that she would not have embarked on the treatment if she had been warned that this complication might have occurred.

She further complained that the young dentist should not have attempted the extraction given the possible complications and she held the dentist responsible for her pain, suffering and loss of earnings while away from work.

Dental Protection drafted letters for him to send in response to this complaint and ultimately the patient accepted that he had acted properly and promptly following this rare and unpredictable complication during a routine procedure.

Easy assistance

The more information that is stored in the records, the easier it is to defend a clinician.

Assisting the clinician in this case was made easy because his record keeping was excellent and he was given support by the maxillofacial surgeon as soon as he requested it. A prompt, accurate referral helped to resolve this complaint satisfactorily without lawyers becoming involved.The case demonstrates the value of keeping good notes and of retaining copies of all correspondence in the file. The more information that is stored in the records, the easier it is to defend a clinician against an allegation of negligence arising out of a referral.

Record your way out of trouble

The quality of record-keeping is often the difference between a positive or negative outcome in a case.

It is important that you:

  • Understand the key legal and professional obligations for completion of treatment records
  • Recognise the key inputs for an acceptable record
  • Build sufficient knowledge to manage the security of treatment records.

Other ways to learn

Free as a benefit of your membership, you can access Prism, our online learning platform, on a range of devices and complete modules at your convenience. Take advantage of flexible professional development offering interactive learning modules, including Record Keeping and case reports, as well as workshop refresher courses. 

For specific advice on record keeping and other dentolegal advice, please contact us.