United Kingdom Edition March 15-21, 2010 Practice Management Tribune 17 such as BpE scores, periodontal probing depths and other indices, tracking of oral pathology and other conditions • Financial records. Although it is sensible to keep these separate from the clinical notes themselves, a record should be kept of all fees quoted and charged and payments made by the patient Tax authorities may request financial data from the dentist and issues of confidentiality can be avoided if the financial transactions are kept as a separate element within the record. processes in which any unpaid fees are pursued should also be meticulously recorded • Correspondence. All correspondence to and from the patient or any third party (including specialists, medical practitioners, other dentists etc) • Consents obtained, and specific warnings given of possible adverse outcomes • Advice. Notes of advice (including oral hygiene, dietary and/or general health advice such as the discontinuation of smoking or attention to other risk factors) • Instructions given pre- and postoperatively to the patient (or parents) • Drugs given, including route, dosages, frequency and quantity ordered. Any adverse reaction to any such medication should be recorded • Anything else that you consider relevant. Here, the patient’s dental history can be particularly relevant. For example, a record should contain the reason why the patient has requested a consultation or examination, and (unless a regular patient) a note of when the patient last received dental care. This is extremely important, especially in the case of a new patient since it is always helpful to be able to refer back to notes made at the initial examination to recall what signs and symptoms the patient was actually exhibiting when he or she was first seen. It is obviously equally important to have a record of what treatment the patient requested or required. Baseline charting A traditional, basic skill which is emphasised at dental school, but which is sometimes lost as a clinician passes through his or her career, is that of a baseline charting. The computerisation of records has played a part in the demise of accurate baseline chartings, since most brands of commercially-available software insert a stylised representation of a specific type of cavity or restoration, in a standard shape and format rather than attempting to create an accurate reflection of the actual situation as it appears in the patient’s mouth. teeth are missing, confusion can easily arise over which teeth are being described. of the records kept, that some dentists take the foolish step of altering or forging their records. “Contemporaneous” means “recorded at the time”, and it is easier than one might think, to identify entries made after the event, or to recognise record cards which have been rewritten or altered. The importance of an audit trail for computerised records is covered separately below. A detailed charting showing Contemporaneous records the size and extent of existing Serious difficulties can arise fillings, provides so much more when a dentist feels the need to information than a minimal re-write or embellish his or her charting which perhaps only inrecords after becoming aware dicates missing teeth and teeth that a challenge or investigation needing immediate treatment. is likely. Few, if any, records are Sometimes the records are found perfect in every respect and yet to contain no indication at all of it can sometimes be due to emwhich teeth are present or abbarrassment at the inadequacy sent, and when several posterior 2453 DPL ad A4:Layout 1 10/08/2009 09:18 Page 1 Records should be in diary sequence with other dated entries, and no attempt should ever be made to “cover one’s tracks” by altering or “improving” an original record card entry, or by substituting a modified record card for the original. Such efforts can easily transform a small problem into a major one, or even into a criminal matter. Courts of law, and the à DT page 18 Don’t read this... ...unless you are interested in: Lower professional indemnity subscriptions Free personal indemnity for every dental nurse and/or dental technician you employ for both clinical negligence and professional matters Free Indemnity for practice managers and receptionists Dispute resolution assistance for disputes between professional colleagues Free annual subscriptions to a comprehensive online information resource including a wide range of business and healthcare legislation and regulatory requirements CPD for the whole dental team Employment law helpline Practice management and clinical audit tools to make your practice safer, more easily managed and more successful An Xtraordinary Indemnity Programme for the Whole Practice For more information go to www.dentalprotection.org/uk/dplxtra or call our Membership Helpline on 0845 718 7187