Dentists: Does your record-keeping need an audit? Stay on top to protect yourself
Protocols for efficient and accurate record-keeping are essential for dental professionals and practices. Should you ever have a claim made against you, the quality of your records will be crucial for defending the care you delivered.
There are plenty of guides available, about how to gather data accurately in a way that is also legally compliant, but one factor that you must not overlook is time. Despite working long, busy days, an omission to make records contemporaneously could prove disastrous down the line and the responsibility is yours, to protect yourself and your patients. Establishing a daily routine will support consistency in your record-keeping; templates are good for proving a structure as long as you include enough unique detail. Audit your processes often too, so you know they can be relied on and that everyone who needs to, understands them.
Standards for record keeping
The BDA has a list of standards for professionals to adhere to for record-keeping, as does the GDC and other professional bodies, with resources that set out principles to follow. Among the legal obligations for clinical record-keeping are ensuring their safe and secure storage. If you work in a practice that stores patient information digitally, seek reassurance from the software provider of a data recovery plan, in the event of a disaster. There are practical things you should do too, like using strong passwords which are changed frequently.
When making your notes, keep in mind that someone with a non-clinical background may one day need to read them. They should be clear, comprehensive yet to the point. Claims can occur years after treatment was completed and should this scenario happen to you, there is simply no way you would remember all the details.
Don’t overlook the fundamentals either when explaining complicated processes. Check the notes you make, and ensure they are signed to identify them as yours. The decisions you made must be credible, so include all the alternative options the patient was given before they gave their consent to go ahead. Additionally, you should add any advice you gave for aftercare and maintenance, and any changes made to their treatment plan (these may come from another professional at the practice and should be documented and signed accordingly).
Disclosing your notes
Ensure you are using all the resources available to you to reduce the risk of not being able to produce quality information when you need to. It is always advised that, if you are faced with a request to disclose your notes, you should contact your Indemnity provider to seek initial advice in how to respond. Howden has been supporting dental professionals of all specialisms, as well as practices, for years, providing cover they can depend on in a wide number of scenarios. Should you face a complaint or claim at any time in the future, with Howden you also get tailored guidance and advice about how to protect yourself, as part of their contract-certain policies.
Record keeping is not always enjoyable, but good for you now, and in the future. Ensure your processes are watertight, audit them frequently and you can feel secure that you will have the right information to hand, when you need it.