John Tiernan, Director of Educational Services at Dental Protection explains the importance of the original patient record when your clinical skills face a legal challenge and emphasises the consequences if a dental professional changes a clinical record in an attempt to cover up a mistake.
A letter from an unhappy patient or from a patient's lawyer can be a very threatening experience for any professional person.
Usually its arrival is totally unexpected, which only serves to exaggerate the level of anxiety experienced by the young clinician.
A natural reaction is for the dentist to look for the clinical records to remind themselves just what happened that day. Sometimes the clinical records are helpful and sometimes they are not. It could be 12 or 24 months since the patient was last seen, and the memory rather vague. It is quite possible that there might be no recollection of the patient at all. It is at times like this that the true meaning (and value) of a complete contemporaneous record really hits home.
There have been many cases where dentists and dental staff have altered clinical records after the event and then tried to pass these as the originals. These attempts to pass off the amended records as original documents are often spotted by the dento-legal adviser assisting the individual dentist which is helpful because it contains, at an early stage, the number of people who might otherwise be misled. There are a variety of tests that can be used to establish whether hand-written records are genuinely original and if it were to be discovered at a later stage in the investigation that they are not, this dishonesty can make matters much worse for the dentist. Some dentists go to great lengths in an attempt to cover their tracks - re-writing old records completely, using different pens and 'distressing' techniques. In fact, all these efforts simply compound the problem and make it worse. The same applies to computer records as every key pressed leaves a footprint which can be forensically analysed.
It only takes a few
Of course, the vast majority of dentists do not alter their records; however, when they have been altered it can create considerable problems with huge ramifications for everyone implicated in the process.
Regulatory bodies will almost certainly take a very harsh stance in relation to any attempt to pass off the altered records as contemporaneous documents. A finding of professional misconduct and the subsequent risk of suspension or erasure is quite possible in such circumstances. Indeed, a doctor was recently sent to prison for altering a patient's record. The same could apply to dental records.
- Destroys professional credibility from the outset because no part of the record can then be relied upon as an accurate and contemporaneous record of what happened during a particular patient visit.
- Damages the patient/dentist relationship. The breach of trust means that the patient can no longer trust anything that has happened in the past and such breach of trust may act as a predisposing factor to the patient taking the matter further.
- Cases may have to be settled that might otherwise have been defended had the original records been left unaltered.
- A clinician's right to assistance from their indemnity organisation can be compromised as a result of this deliberate and misleading act. A contracting body could regard this as a fraudulent act, thereby providing grounds for the termination of a contract.
- Possible criminal prosecution for fraud, counterfeiting or criminal deception.
The natural reaction by a recently qualified dentist on receiving a dento-legal challenge and realising that their notes are inadequate is to panic; however, there can never be a justifiable reason for altering a record after the event - so don't be tempted.
The key factor to remember in this situation is that the past cannot be altered. It is far better for a practitioner to admit to having a poor record and to learn from it, than to have to admit later that the records are not contemporaneous, with the effect of destroying your professional credibility and reputation in the process.
It may be that there is something inaccurate in a patient's record. In which case it is justifiable to alter and amend records provided that the extent and the date of the amendment is clearly indicated and is marked as such. Indeed patients have a right to ask for records to be altered and amended if they contain any inaccuracies.
When altering or amending a record it is important to make it clear that the new entry is an amendment. Previous entries should not be deleted or crossed out in a way which prevents them being read. The new entry should be placed in chronological order and dated. Sometimes the practitioner may have remembered something after the event, in which case the new entry should be dated so that the record is contemporaneous, ie. the date on which the record was entered on the chart is clearly stated, even if it refers to treatment that took place on a previous date.
It is also important to try to avoid adding notes down margins or in areas that could give rise to an impression (or an allegation) that the record was non contemporaneous. The best set of records is one that is in chronological order with each visit clearly marked out.
Electronic records should have an audit trail which does not allow the deletion or over-writing of the previous records. Modern software is written with such steps in mind. Some older or self-written systems may need to be checked to ensure mistakes and inadvertent amendments cannot be made.