Keeping good patient records is vital to enable clinicians to provide a high standard of patient care, and it is imperative for risk management. Keeping comprehensive, accurate patient records is integral to demonstrating that valid consent was obtained.
The General Dental Council say:
You must make and keep contemporaneous, complete and accurate patient records.
Excellent records go further than simply listing a factual sequence of events. They also provide evidence of the thought processes that lie behind the decisions that were made. They will also provide a lot more useful detail and because of this, they can anticipate and provide the answers to all the key questions that might be asked in the future arising from a treatment that was provided (or sometimes not provided).
The General Dental Council say:
But…
The potential role of templates in poor record keeping
‘Poor’ records are not just about keeping records with scant detail. Poor records can also result from the inappropriate use of pre-filled templates. For examinations (new patient and recall), the best and safest templates contain only prompts for what should be recorded. Patient records that all look the same ring alarm bells with the GDC and make them question whether the records are accurate.
The dangers of using pre-filled templates in an extremely busy practice are multiplied because time pressures can lead to a failure to edit the template appropriately, meaning there is a significant danger that inaccurate records are made and kept.In the event of litigation or an investigation by the GDC, the results can be catastrophic for the clinician, not least because inaccurate templates mean that the records will be used against the clinician rather than as an effective defence.
Patient records – Do’s
Do:
- Be factual, consistent and accurate.
- Write legibly in ink (to allow scanning or copying) on paper records.
- Date all entries.
- Identify the treating clinician, dental nurse and other individuals, if relevant, e.g. another clinician who provides help or a second opinion.
- Score out any errors with a single line and date and sign the correction.
- Record the patient’s presenting complaint (if any) in his/her own words.
- Record positive and negative findings.
- Demonstrate the chronology of events.
- Identify each page with patient details.
- Number the pages of paper records.
- Secure all papers within the folder.
- Apply the same principles to electronic records.
- Only use templates wisely and cautiously.
- Write your records at the time you see the patient (contemporaneously).
- Remember that patients have the right to access copies of their records.
- Secure all papers within the folder.
- Apply the same principles to electronic records.
Patient records – Don’ts
Do not:
- Ever write derogatory comments.
- Create a false record by recording an inaccurate date.
- Use abbreviations and unexplained initials.
- Allow the pages to become jumbled.
- Write your records up at lunchtime, at the end of the day, or at any time other than when you see the patient.
The benefits of working with a trained dental nurse
You will reap many benefits from training your dental nurse to capture and record information accurately. Your nurse should also be trained to prompt you discretely if you miss any element out of an examination e.g. radiographic justification or report, soft tissue examination, BPE etc.
Working in this way allows the clinician valuable time to build rapport with the patients.
There is much evidence to suggest that clinicians who have taken time to build rapport with their patients have fewer complaints than those who spend more time recording information than interacting with their patients.
How can you keep on top of record-keeping compliance?
Regular Auditing – All clinicians should audit their patient records regularly to ensure they are accurate and comprehensive. Our automated patient record audit provides a simple way to identify good practice and also any areas that may require improvement.
Keep up to date with Patient Records CPD – We have four online Patient Records courses:
- The Good, the Bad, and the Ugly
- What does ‘good’ look like?
- Referrals
- Gaining Valid Consent to Treatment
The total duration of the four courses is 3 hours and 30 minutes.
Further Reading:
Dental mythbuster 8: Dental care records – Care Quality Commission (cqc.org.uk)
This is a great read from Dental Protection: GDC standards Q&A – Principle 4 – Maintain and protect patients’ information (dentalprotection.org)
