18 ß DT Practice Management Tribune United Kingdom Edition March 15-21, 2010 page 17 dental registration bodies take an extremely serious view of non-contemporaneous records being presented and stated, dishonestly, to be the originals. Computerised records Many practices now keep some (or all) patient data on computer, and this either duplicates or replaces handwritten information. Even if you keep some or most of your records on computer, you may still need some manual records eg for non-digital x-rays, correspondence etc. It is no defence in law that your computer broke down or you lost data, for whatever reasons. It is up to you to ensure that you can always produce, whether directly or indirectly (created from computer records), all the same information that has been discussed above in respect of paper records. Being computerised is no justification for cutting corners in record keeping – indeed, quite the reverse. There appears to be a tendency for records kept in computerised form to be less detailed, perhaps using more abbreviations and codes that are specific to the chosen software. It is worth spending time before a problem arises, evaluating the quality and quantity of the records you are keeping and the safeguards and controls (eg computer back-up) you are operating in order to protect them. Many clinicians fail to appreciate that changes to computerised records may still be captured on, and retrievable from, the hard disk, even when the original entry is deleted or modified. Computerised records need to have a robust and secure audit trail, showing who made each entry or amendment, at what time, on what day etc. The same details should be available for each historical entry, so that the whole evolution of the final version of the records can be tracked with certainty. Without this safeguard, the value of the records may be seriously reduced. Checklist 1) Carry out a random audit on a selection of your patient records and ask a colleague to check that they are legible and comprehensible. Involve your dental team in this process. 2) Ensure that the notes you write, or type, include the kind of detail described in the text. 3) Try to avoid using ‘shorthand’ or abbreviations that others are unlikely to understand. 4) Remind your staff of the need to ensure that the patient’s details are regularly checked for accuracy and updated, and stress the confidentiality of clinical records. 5) Review the space available for the storage of old records. Rather than destroying records when a storage prob- Contact Information We are the world’s largest specialist provider of dental professional indemnity and risk management for the whole dental team. The articles in this series are based upon Dental protection’s 100 years of experience, currently handling more than 8,000 cases for over 48,000 members in 70 Countries. 33 Cavendish Square, London W1G 0pS, UK E-mail: General enquiries, querydent@mps.org.uk The complete set of 36 risk management modules can be ordered from lynne. moorcroft@mps.org.uk www.detalprotection.org lem arises, consider scanning records and x-rays and retaining them on CD-ROM or DVD in digital form, together with digital photographs of study models (which may be particularly helpful for orthodontists who face special storage difficulties). 6) Check the specific legal situation which applies in the country where you practice, regarding how long records need to be kept and any requirements for disclosure of records, or a patient’s sta-tutory right of access to their record. DT be individual Your practice belongs to you, that’s why we make it our priority to help you develop a plan that fits into your own unique brand and personality. So, if you’d like your identity back, please get in touch. 01691 684135 www.practiceplan.co.uk G11060 PP Switch Ad.indd 1 19/2/10 14:51:32