16 Practice Management Tribune United Kingdom Edition March 15-21, 2010 Clinical records Keeping proper records of the care and treatment we provide for our patients is an essential aspect of an overall duty of care, says Dental Protection Recording the warnings and explanations given prior to the removal of an impacted third molar is an example of this; keeping records which monitor the progress of a patient’s periodontal health is another. Noting that the dentist has checked or updated a patient’s medical history is a self-evident requirement – but noting the clinician’s specific recommendation that the patient should return if symptoms do not improve, may be less obvious. Either could prove pivotal in determining the outcome of a case. A dental nurse/assistant is ideally placed to provide an additional level of backup, ensuring that all key conversations between dentist and patient, all discussions, warnings, explanations and advice are recorded in the notes. On a busy day, when the dental team is under pressure, the crucial details can so easily be overlooked. Think records, not record cards Many dentists fall into the trap of believing that the clinical records only consist of the written (or computerised) notes of a patient’s treatment history, detailing what treatment was carried out, when it was performed, and occasionally including financial records of what fees were charged and when they were paid. Nothing could be further from the truth. The totality of the record of a patient’s dental care could include many (or all) of the following: • The treatment notes • The current and historical medical history • Radiographs (and any associated tracings), prints from MRI and other imaging • Results of other investigations (pathology or radiology reports, pulse oximeter printouts etc) • Study models/casts • Diagnostic records (bite registrations, stents, diagnostic wax-ups etc) • photographs (including intraoral camera images) • Correspondence • practice documentation of various kinds • Other sources of information which might refer to the patient: a) Laboratory tickets and invoices b) Other invoices (eg for implant fixtures) c) Financial records d) Appointment books/daylists Many of these records may be held on paper, others in compu- terised/digital form. Either way, the records are only helpful if they have been preserved and remain available at the time they are subsequently required. What should a dental record contain? • The patient’s name, and contact details (address, preferred telephone/fax/e-mail or other contact details). It is important to keep this information up to date, as it may be needed in an emergency situation • An up to date medical history. A full medical history (including a note of any prescribed or self-administered medication) should be taken at the initial examination and updated and checked for any changes at each subsequent visit. It is also helpful to have a note of the patient’s medical practitioner. Everybody realises the importance of taking a full, written medical history at the time of the first examination of a new patient. The problem often arises, however, that at subsequent recall examinations (check-ups) the medical history is not formally updated, and no written entry is made on the notes to the effect that the clinician has confirmed that the medical history is unchanged • Treatment information. The date, diagnosis and treatment notes every time a patient is seen, with full details of the treatment carried out. This should specify the teeth treated, materials used, and clinical findings as the treatment proceeds. An accurate record of positive findings and signs (what you can discover for yourself) and symptoms (what the patient tells you about the problem) are important, so also is the absence of them (tooth not tender to percussion, lymph nodes not enlarged, no swelling, not painful, no change in medical history etc). These notes should include a summary of any particular incidents, episodes or discussions (for example, if a patient declines a referral or other treatment recommended for them) • Missed appointments. The date and details of any appointment offered to a patient but declined, or which a patient fails to attend, or cancels, or when the patient arrives late and/or needs to be re-booked • Phone contacts. Dates and details of any telephone conversations with the patient, whether this involves the dentist or other dental team members. Similarly, any fax or e-mail contact should be retained within the records • Investigations. A summary of each investigation carried out with a note of both positive and negative findings. This should include monitoring information Clinical module 20.3. Financial data that is kept separate from clinical details avoids confidentiality issues when shared with others ecord keeping is one of the basic principles that we are all taught at dental school, and this message is continually reinforced throughout our practising careers through lectures, publications and personal clinical experience. Dentists often protest that they have been trained to treat patients, not to spend their professional lives writing endless notes for every patient that they see. This reaction may be understandable, but there are many reasons why it is important to keep clear, full and contemporaneous notes of the care and treatment provided. The irony of record keeping and paperwork generally is that it is the part of dentistry that most dentists actively dislike. Consequently, many dentists spend as little time as possible on it, perhaps because it is often seen as a distraction from (and less important than) the main task - the clinical work itself. This can leave the dentist exposed and vulnerable to problems on all fronts. Every member of the dental team can play a valuable part in ensuring that the practice’s record keeping is of a high standard. poor record keeping can make it difficult or impossible to defend allegations of clinical negligence, or professional misconduct. It can also lead to disputes over money, can cause mistrust and confusion, and can lead directly to complaints. Endless hours of “fire-fighting” can be wasted in trying to resolve problems caused by poor record keeping, and it can even lead to the most serious (and fatal) con- R ‘Serious difficulties can arise when a dentist feels the need to re-write or embellish his or her records.’ sequences; on some occasions, the records we make can change the entire course of our professional career. Why keep records? It is a common misconception that records are simply an aide memoire for the personal use of the dentist, In many parts of the world, patients have a legal right of access to their records, and to obtain copies of them upon request. If and when any problems arise, other bodies such as investigatory bodies and statutory authorities, Dental Councils/ Boards, and experts and forensic odontologists or coroners acting on behalf of the courts will often examine records. In health funds and similar payment systems, they may be inspected by officers of these agencies, or by insurance companies. If there is intended litigation or disciplinary action being contemplated against a dentist, then the records could be disclosed to patients’ legal or other representatives. Many parts of the world are becoming increasingly litigious and good record keeping can provide vital evidence of the proper level of skill, care and attention that a patient has received. Sometimes there will be a conflict of evidence between the versions of events given by the patient and the dentist respectively. In such situations, the patient’s version is often preferred unless the records can provide clear evidence to support the dentist’s account of events. It is often argued that the patient is much more likely to recall the events of a single dental appointment, with a given dentist on a specific occasion, than the dentist for whom this will have been one of many patients seen on that particular day, and with many more patients having been seen since the time in question. Adequate records will allow a clinician to reconstruct the details of a patient’s dental care, without having to rely upon memory alone. Excellent records go further than this, because they provide evidence of the thought processes, which lie behind the decisions that were made. They will also provide a lot more useful detail and because of this, they can anticipate and answer all the key questions that might surface in the future, arising from the treatment provided (or sometimes, not provided). A logical approach Knowing what details are likely to be relevant, or irrelevant, from a dento-legal perspective, comes either from bitter first-hand experience, or from developing a better awareness of risk management through publications, lectures and other sources. It is important to understand the particular risk management issues that tend to arise in relation to each of the procedures that you carry out, especially those which are carried out frequently.