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Five tips to aid your dental record keeping

Post date: 31/08/2014 | Time to read article: 2 mins

The information within this article was correct at the time of publishing. Last updated 14/11/2018

record-keepingThere is never a bad time to review the way that you keep records of dental patient treatment.

Indeed, complete and accurate clinical records are central to the care you provide to your patients and also to your own professional wellbeing. They can also play a key role in protecting your career in dentistry.

1. Have an eye for detail

The importance of detailed records cannot be overemphasised although it may be time consuming. Your records are the primary source for contemporaneous evidence of the treatment you provided. Complaints to the Dental Council often arrive months, if not years, after the event and can relate to routine matters about which you won't have thought twice, either at the time or since.

2. Stay informed

Your patients must give their consent to any treatment that you provide. No doubt they do, but allegations of a failure to obtain consent feature all too frequently in complaints to the Dental Council. By far the easiest way to rebut such an allegation is to record the consent process at the time it happened. For consent to be valid a patient must not only understand the benefits of treatment, but also be advised as to the risks and potential complications involved. It is therefore essential that you record all of your advice, as well as the patient's specific agreement to the procedure in question.

3. Have an eye to the costs

Complaints often arise from misunderstandings as to what patients perceive to be costly and unplanned dental treatments. Not only should you keep copies of the estimates sent to patients but you should record discussion about the costs in your notes. Where unexpected treatment becomes necessary, ensure that you record your discussions about any associated charges and provide the patient with an updated estimate as well as keeping a copy.

4. Accept the rough with the smooth

It is important that if things do go wrong, not only should you be up front and honest about it with the patient, but you should also make a detailed record of the treatment itself and any advice that you subsequently give. Equally, if the patient raises a concern or expresses dissatisfaction, even when you think everything has gone to plan, make a note of the facts together with any reassurance or advice you give the patient and the action you take.

5. Resist temptation

Finally, if you do receive a complaint, do not, whatever you do, ever be tempted to alter your notes. Your dental records must be contemporaneous. Even if your intention is simply to clarify or expand on the treatment that you provided, if you want to augment the information after the event, you should be sure to clearly record the date and time of the subsequent entry. Whether you keep handwritten or computer notes, subsequent amendments are almost inevitably uncovered and may lead to allegations of dishonesty, the consequences of which are likely to be far more serious than the matters underlying the original complaint.

As with all aspects of dentistry, you should exercise professional judgement and common sense in your approach to record keeping.

Dental Protection is the leading indemnity provider.
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