Record-keeping is good for you!
14 April 2023
If you asked a group of dentists which part of the job they disliked the most, there would almost certainly be a strong showing for ‘record keeping’.
The importance of records
The problems that could arise if you haven’t got quality records could cost you dearly, in terms of time, stress, reputation and money. Poor, incomplete notes will leave you vulnerable if a patient complains, whatever the reason. Failed treatment, a lack of information, a dispute about their bill… in a public-serving profession like dentistry, you are unlikely to avoid scenarios like these.
Patients’ expectations are sky-high, they want – and deserve – the best. But things do go wrong and this is why your record-keeping needs to be meticulous. It is crucial to people’s safety and essential to your professional reputation. When a patient is dissatisfied and makes a complaint, your notes will be the primary source of evidence. If someone has made a claim for negligence, your records could be pivotal to the outcome and fundamental to your career.
So rather than seeing it as a distraction from the ‘real’ clinical work, quality record-keeping is something you should be striving to achieve at every appointment.
The key to keeping quality notes
The ‘how’ you make and keep records could make the job more tolerable, as well as improve the quality of your notes. Devise a protocol, to give you a framework and blueprint for consistency. The key to ‘how’ is that your records should be made contemporaneously, ideally when the patient is in the chair and the treatment is being delivered. The dental nurse is therefore the ideal person to share the task of record-keeping with, ensuring that all the necessary details and conversations are being recorded clearly and in real-time. A busy schedule is no excuse for notes that are incomplete or inaccurate. Contemporaneous records avoid any reliance on memory, to piece together the sequence of events during treatment that may have been delivered months or even years ago. With the growing trend for late-reported claims, this is vital.
But even records made at the end of the day will not be considered contemporaneous, because perfect recall can be compromised by all sorts of things – tiredness, mood – and inherent bias if you know the patient complained to the receptionist after leaving your practice room.
Quality notes won’t just list what happened and the actions taken, but also the reasons for taking them. They will give an insight into the decision-making process that led to the diagnosis, and why one course of treatment was recommended over another. They will detail the options and alternatives offered, and what maintenance advice was given to ensure the outcome remained stable. Other information you should expect to find in high-quality records includes the techniques and materials used and any changes and developments to oral health, post-treatment. If a patient could not attend a scheduled follow-up, or cancelled it without rebooking, this is also relevant. If treatment is ongoing, for example for periodontal disease, include everything that relates to how progress is being monitored, such as BPE scores. Don’t forget the fundamentals too, like contact information, consents obtained, correspondence with specialists or the referring dentist, notes from the lab and financial reports. Your records may be a mix of electronic and paper, and will create a complete picture so that anyone who accesses them, even if they don’t come from a clinical background, can understand them. Regarding computerised records, apply the same principles of detail and legibility as you would to handwritten notes. Whatever system you use, ensure it offers security, not just in terms of what happens if there is a cyber-attack, but it must also show who made an entry, or amended a file.
Quality record-keeping is about having protocols based on common sense and sound judgement. You don’t always know that a patient is unhappy until you receive a complaint, or get a request for their records. So, think about the ‘what ifs’ and remember that great notes are good for you! Poor record keeping could simply give you one more thing to worry about.
Protection against patient claims
Your record keeping is just one way you can protect your career, well-being and finances if a patient pursues a claim against you. Another is by having robust, contract-backed dental indemnity in place, such as the offering from specialist broker, Howden. You’ll have the right people by your side, when you need them most.
The two things to have in mind when taking your records is that anyone could read them, and anything can happen. There are plenty of claims made against dentists several years after treatment, where the facts of the matter are now in dispute due to poor records taken at the time. Learn to love record-keeping – it’s a way you can protect yourself now, and in the future.