Simplyhealth Professionals’ Dr Catherine Rutland speaks about the Art of Self Defence at BDIA Dental Showcase
Proper record keeping is essential in our modern litigious dental environment. Keeping patient records secure is just as important, as Dr Catherine Rutland, head of professional support services with Simplyhealth Professionals, detailed during her talk The Art of Self Defence in the Future Experience Theatre during Dental Showcase 2018.
Dr Rutland pulled no punches during her presentation to a packed theatre filled with dental professionals. She began by stating that it is almost impossible for the dentist to write accurate notes on their own – its always best to involve the team. If a third party keeps the notes they are more likely to produce contemporary records that are complete and accurate. What follows is a Dental Review record of Dr Rutland’s talk.
You need to keep records itemising the advice and guidance offered to patients at the time of their appointment. You must record what you say and the language you used when you said it, and the patient’s response. If your nurse is keeping accurate notes you might be amazed at what you actually said when you read them back, and what a patient might claim you hadn’t said at a later date when something goes wrong.
And this isn’t just about dealing with legal claims. Accurate notes benefit the entire team. For example, if your patient presents for emergency treatment and is seen by someone else in the practice – or you’re seeing another dentist’s patient – legible notes are essential to a successful outcome.
Detailed records can also help identify a patient’s oral health trends, guide accurate diagnosis, and support properly monitored health. The fact is, said Dr Rutland, we think we remember everything we say, but we can’t. Those records will help guide future treatment planning.
A lot was made of GDPR when it arrived, but it has not changed much in the way dental practices keep their records. The profession has always been very good at keeping patient details secure. However, if a patient is deceased you must be careful who you release copies of any records to, even a member of their family. It would be best to get advice on the matter from your defence organisation. The same is true when records are over 10-years old and might be suitable for destruction. Again, take advice.
And never hand over original records, only ever provide copies. The person who gets into trouble if records are released incorrectly is the dentist, never the patient or a member of their family. Regarding the question of releasing copies of records, there should be no charge for this – within reason. If there are intemperate requests for copies you should monitor the cost to your practice and consider charging accordingly.
What Should be in the Records?
According to the FGDP(UK) Guidelines 3rd Edition, published in 2016, dental records should meet one of the following criteria:
A – aspirational, what you should like in an ideal world
B – basic, the absolute minimum required for the required outcome
C – conditional upon the circumstances
The records must contain the following information:
• Personal information
• Medical history
• Reason for attendance
• Information regarding the manufacturer of any dental devices/prosthetics
• Examination notes
• Study models
• Audio-visual recordings – if any
• Treatment options, including discussions with the patients and any decisions made
Some of these items are obvious, but others require extra attention in the notes. For example you will need to justify any radiographs and detail what’s there, even in areas you are not specifically interested in at the time. If something requiring attention is missed you may be liable.
Photographs, it’s tempting to take photographs using your smartphone. Don’t, they can be accessed or hacked. Your phone is an absolute no-no. Study models are part of the clinical notes, once scanned they can be kept virtually. Working models, however, are not so important.
Video and audio-visual records are coming into fashion because people believe they save time; but be wary. Think about physical leakage. When dealing with a patient consider what your face is saying, even if you say nothing.
Treatment options discussed are important to record, even if the patient says no to a proposed treatment. Consider the repercussions if another dentist says something you suggested should have been done and the patient claims you said nothing about it. Write it in the notes.
The Statement of Manufacture for any dental device must be kept with the clinical notes along with any laboratory prescriptions. And keep a note of any diagnosis; for example if you diagnose periodontal disease you must always write it down – no matter how often you diagnose it.
DEPPA, and Trauma
The Simplyhealth Professionals’ Denplan DEPPA patient assessment system (https://www.denplan.co.uk/dentists/denplan-excel/deppa) is very important because it acts as a visual aid that helps dentists explain why they have to do what they propose to do – while engaging patients in their personal care. Bringing patients on-board and making the accept some of the responsibility for their oral health is the cornerstone of effective preventive dentistry.
And finally, what must be in the records following trauma? The dentist needs to keep a clear head in this situation. Prior to examining the patient you must record how the injury occurred. Has there been any period of unconsciousness? Is the patient suffering from headache or nausea? Is there evidence of a previous injury or a disturbance in their bite? Are they reacting excessively to hot or cold?
All this must be assessed before you look in the patient’s mouth. Perhaps dental work is not the first priority, no matter how much you wish to help. Assess the damage then act on it calmly.
During the clinical examination following trauma you must precisely record any injuries and the presence of any foreign bodies. How is the patient’s mobility? How do they react to percussion, and what are the results of vitality testing? Explain why you take any radiographs, especially any extras, and how you recorded the patient’s occlusion.
Keep photographic evidence, take photographs before you start and upon conclusion of treatment. Ensure you review any advice you offer, record it, and include the patient response. If something goes wrong – or the patient is unhappy with the outcome – they may deny everything you have advised or done and take their case to legal. Your records may be your only form of legal self-defence, it’s up to you to ensure they are legible relevant, and comprehensive.