Evelyn Ferguson-Williams, Dental Case Manager at Dental Protection, explains the record keeping responsibilities of dental nurse, which are an essential part of their daily routine.
Accurate records are essential for ensuring patient safety, documenting patient history and treatments, and complying with legal and regulatory requirements. In this article, we will discuss the importance of record keeping in dental nursing and provide some tips for maintaining accurate dental records; after all, Record Keeping is an essential part of the daily task dental nurses assume.
Why is record-keeping important for dental nurses?
Patients’ notes are legal documents and often serve as evidence in supporting practitioners through communicating material risks to their patients per the Supreme Court ruling in the case of Montgomery v Lanarkshire Health Board which transformed medical litigation.
Although responsibility ultimately lies with the treating clinician to ensure the records accurately present the clinical and radiographic findings and adhere to current standards, dental nurses have a vital role in achieving this through effective teamwork.
A dental nurse would be expected to cover the anatomy of teeth and supporting structures as part of their course curriculum, such as dentition, growth and development, functions of teeth, teeth components and surrounding bone and periodontium. Therefore, it is common for dentist colleagues to dictate clinical findings to their nursing partners in dental charting teeth and tooth surfaces alongside basic and advanced periodontal documenting. Duties would also include updating the medical history, filing any communication with specialists and other clinical-related correspondence.
General Dental Council (GDC)
The GDC guidance clearly states that all clinicians must ‘make and keep accurate and complete patient records, including a medical history, at the time you treat them’. In addition…
- Personal details be kept confidential
- A patient should be able to access their dental records
- Dental records should be stored securely.
But what does the GDC consider an accurate clinical record?
Periodically the GDC shares insights from their fitness to practise investigations and, in their published 2020 report, advised that in the first three quarters of 2019, 7.5% of all cases referred to the assessment stage included a concern about record keeping.
The GDC further states that …
“To comply with the Standards, you must make and keep contemporaneous, complete and accurate patient records. You must record as much detail as possible about the discussions you have with your patients, including evidence that valid consent has been obtained. You should also include details of any particular patient’s treatment needs where appropriate.
How you meet this Standard, and the level of detail you provide is a matter for your professional judgement. The GDC does not define good record keeping, but directs dental professionals to the relevant laws and guidelines on record keeping, for example:
- Dental Record Keeping Standards: a consensus approach (NHS England and NHS Improvement).
- Clinical Examination and Record Keeping (FGDP UK).
- Health and social care advice from the Information Commissioner’s Office”.
As well as reviewing fitness to practise concerns, the GDC inspect and quality assures training programmes publishing their report findings on their website. In examining the National Examining Board for Dental Nurses (NEBDN) programme, the GDC reviewed completed Personal Experience Record sheets (PERs) and overall Records of Experience (RoE). As part of the Providers’ requirement, systems must be in place for patient agreement to treatment. The student dental nurse must obtain, and record consent before treatment commences to meet this requirement.
An example statement from the GDC inspection report for NEBDN 2017 is demonstrated below:Requirement 2: Providers must have systems in place to inform patients that they may be treated by students and the possible implications of this. Patient agreement to treatment by a student must be obtained and recorded prior to treatment commencing. (Requirement Met)
Each time a student completes a clinical task, they must complete a ‘Personal Experience Record sheet’ (PERs), which includes a section for reflection and must include the statement: ‘Patient consent was gained for a trainee dental nurse to assist the clinician prior to treatment.’ Each PERs is completed in practice under the observation of a GDC registrant who has undertaken the NEBDN training to be the designated practice ‘Witness’. The Witness ensures that consent has been obtained prior to any treatment being carried out.
The PERs are included as part of students’ overall ‘Record of Experience’ (RoE), and the inspectors noted evidence that patient consent was obtained appropriately when they sampled a number of RoEs.
Each provider has at least one internal moderator, whose tasks include reviewing each student’s RoE, to check that patients are consenting to treatment and that this is being recorded properly. If this is not the case, the internal moderator will contact the Witness and student, requesting that PERs are completed again, or are amended in the RoE. NEBDN QAAs will also review a sample of RoEs during their audits, again to make sure that consent is being obtained and subsequently recorded.
In improving record keeping quality, the GDC advocates upskilling dental nursing staff, recognising dental nurses’ advantageous position within teams, in Spotlight on record keeping:
‘We recommend that dental professionals consider:
- Training dental nurses to assist with notes.
- Providing information upfront to patients and providing them with a few days to agree to treatment and give consent.
- Ensuring the training of the dental team is up to date on data protection, record keeping and processes for transferring patient records.
- Recording information straight away and not overwriting records to correct mistakes.
- Undertaking an audit of patient records’
With the above in mind, early in a dental nurse career, recording consent for treatment is instilled, and the GDC expect this approach to continue complying with their standards. Consequently, everyone within the dental team is responsible for managing records appropriately.
What information conforms part of an excellent clinical record?
Firstly, good record keeping benefits the Provider, clinician and patient by helping to ensure the continuation of care. For example, it is not unusual for patients to see several team members, and in examining the patient, the clinical records will be relied upon in understanding any previous patient concerns, diagnosis, management, and follow-up, as well as enhancing communication between healthcare staff.
Clinical records also play an essential part in Forensic Dental Identification, given that teeth are considered the most surviving tissue in postmortem events. Equally, dental practitioners must monitor the development of the dentition throughout a patient’s childhood and adolescence, and identification of the position of permanent maxillary canines should routinely form part of the dental examination, with the dental chart updated as necessary.
Consideration must also be given to those patients who embark upon gender reassignment because when a patient changes gender, they are given a new NHS number, with NHS England advising that GP practices register individuals as new patients. Referring patients to secondary care often requires their NHS number. Therefore, being aware that subsequent changes to gender establish a new patient record and NHS number can help mitigate referral delays and patient safety incidents.
Patients’ details, including their date of birth, address, telephone number and, if available, an email address. It can be helpful to update this information frequently and at the same time as checking the medical history.
Another critical update that is often forgotten is patients’ emergency contact details. For example, are the named contact person (s) still current and contactable in an emergency? Such information can be more challenging to update for the vulnerable or those with additional needs who may attend with several carers.
The GDC advises that every time you treat a patient, their medical history must be up to date. Although a patient may have previously been fit and healthy, it does not follow that they may be in the same position six months later. A new medical condition could have been diagnosed, or a new drug may have been prescribed. Certain medications can have a detrimental effect on oral health and the dental treatment available within a general dental practice setting, such as bone density and wound healing from medication-related osteonecrosis of the jaw.
In their Knowledge Base, the NHS Business Service Authority advises, “Medical histories should be updated at the start of each subsequent Course of Treatment (CoT) and, ideally, signed by the patient and performer at each update”.
Following the status quo, the College of General Dentistry Clinical Examination and Record-Keeping Good Practice Guidelines maintain that “at a recall exam, the medical history should be confirmed, dated, and initialled by the patient and the dentist. This form can be ‘pp’ on behalf of the dentist by a suitably trained DCP who would verbally advise the dentist of change, if any, so that the dentist is informed. Any changes should be noted, the form dated and initialled by the patient and the treating clinician.”
Socio-behavioural history can also be considered part of the medical history and should be updated accordingly. This can be information given when specifically asked or occasionally disclosed in a general conversation. The socio-behavioural record can include the following:
- Tobacco/smoking habit.
- Alcohol consumption.
- Recreational drug use (the patient may not wish to divulge).
- Eating habits.
- Dietary information.
- Participation in contact sports.
- Playing musical instruments involving the use of mouthpieces.
There should be a record of a patient’s attendance history, including all dates and times of appointments if they attended late or cancelled at short notice or even failed to attend. NHS England has voiced how missed appointments cost the health service millions, with many service providers encouraged to notify patients should they fail to attend; a letter is sent reminding them of any relevant cancellation or Did Not Attend (DNA) policy.
Adopting this approach strengthens the Provider’s position should they later withdraw care, and the appointment history will support that the patient’s attendance breached the procedure and the earlier letter provide an audit trail of communication they had previously been warned about. Such information is now quickly recorded, and retrievable with the developments in the computerised systems many practices now choose to use.
A dental chart illustrates the patients’ current dental presentation and any treatment they may have had, on each surface, on each tooth. When a patient first attends a practice, a baseline chart is recorded, showing all the teeth present and any treatment undertaken. It is a vital part of a dental nurse’s role to check and update the chart each time a patient attends. While dental charts help represent a patient's current clinical status, they aid diagnosis and treatment planning; they have other important uses, as discussed earlier, such as the forensic identification of bodies. This is an example of why it is of the utmost importance that a dental chart is checked and updated regularly.
Two central tooth notation systems are used in the United Kingdom, the United Kingdom Palmer notation system and The International Dental Federation two-digit system. Although the United Kingdom Palmer system is used more frequently, both forms of notation are entirely acceptable. A dental nurse should be able to use whichever approach the dentist they are assisting prefers.
A dental nurse must update the findings of a Basic Periodontal Chart (BPE), six-point pocket chart, mobility, plaque, bleeding or surface wear charts.
The detail contained within the dental notes should be such that all can understand them; the patient, practitioner and any authorised third-party reviewer and include details of the dental history, presenting complaint, examination, investigations, diagnosis, treatment options, and discussions about any associated risks and benefits.
If a patient is undergoing treatment, detailed notes of the provided treatment should be made, including the accurate site notation. Records should be made of the treatment techniques and relevant information to materials and the aftercare discussions.
Clinical notes should always be made contemporaneously, and only in exceptional circumstances should any notes be retrospectively completed. There are occasions when patients might ask for their data to be corrected. The decision and responsibility to amend records would fall to the Data Controller, who will likely discuss the request with the treating clinician to understand any alleged inaccuracies. Furthermore, a dental nurse should be mindful that patients may request a copy of their records at any given time, so they must be written professionally with no speculation or offensive remarks.
The treating clinician should review the recorded information before any clinical notes are completed, allowing them to make any additions or changes that they feel are necessary before the notes are finalised.
Autogenerated templates are often used to save time and with the added aid to ensure that all information and checks are completed. Whilst clinical note templates act as a good checklist, Dental Protection has seen many practitioners criticised for failing to populate the template. As such, templates have introduced an unnecessary challenge by failing to tailor the notes for each patient and any clinicians who subsequently treat the patient.
A dental nurse’s scope includes processing dental radiographs. Therefore, with appropriate support, a practice might request radiographs to be mounted and orientated correctly. Although dental nurses will be familiar with viewing radiographs, they should not attempt to interpret or complete the radiograph reporting requirements on the dentist’s behalf unless dictated by the treating dentist.
Any specialist hospital letters, emails, or telephone calls regarding a patient’s clinical care are part of the clinical record. They should be retained with the digital form or the patient’s physical record card. Should a practice choose to scan all paperwork into a patient’s digital record, the hard copy should be appropriately disposed of, following as one example, the Records Management Code of Practice Guidance. Any telephone correspondence regarding or with the patient should also be recorded and retained as part of the clinical record.
Dental nurses are vital in maintaining and protecting patients’ healthcare data. Working together and allowing nurses to extend their scope of duties to include note-taking helps the record be contemporaneous, as they can often record information while the patient is telling their story. For the practitioner, it also offers reassurance that vital information is unlikely to be missed allowing clinical findings of the hard and soft tissues to be dictated in real-time.