The importance of accurate and detailed dental records is threefold:
- To comply with General Dental Council ('GDC') record keeping requirements;
- To demonstrate care and competence;
- To assist in clinical management – by allowing practitioners to record patient concerns and issues; to see a full picture of the patient's oral health; to review changes and make a diagnosis; and to identify any patterns/progression or deterioration which can be discussed with the patient as well as the necessary care/advice plan.
Common Challenges and the impact on Legal Claims
Common challenges associated with keeping good dental records include:
- The dentist relies on the dental nurse to write/input the record of the consultation (and does not check the records before closing the consultation). Whilst it is common practice for the assisting practitioner to record the charting whilst the dentist is checking the dentition, the records should then be reviewed and finalised by the treating dentist at the end of every attendance. Records should also be clearly signed/attributed and dated. Problems in legal claims arise when many years have passed, the patient cannot be recalled and unclear clinical records make it difficult to establish what happened on the date of examination, which make it difficult to prepare a robust defence as key factual information may be missing.
- The dentist uses a digital auto-template when preparing their records, and updates only those sections of the template which are relevant to the current examination leaving the rest of the template unchanged. This can lead to questions as to how reliable, contemporaneous and accurate the record is and can raise doubts as to whether a complete clinical record was taken. To illustrate this point, we have seen:
- A patient's dental records marked as 'smoking cessation advice provided', however the patient is an 8 year old child and clearly would not be smoking!
- Dental records in which the oral hygiene section may be marked as 'fair' but the text notes later record a conflicting entry which says 'poor oral hygiene'.
- The dentist only records 'issues' or 'positive findings' on the day of examination. However, it is important to note down as many details as possible including;
- Issues discussed
- Treatment options
- Where a 'no treatment' option has been considered
- Negative findings such as no enlarged lymph nodes or negative oral cancer checks (as this is evidence that the necessary checks have taken place)
- Medical history, oral hygiene and smoking status, even if these remain unchanged
- Consenting discussions
- The recall period which has been set and the reason for the chosen recall period
The clinical records should include as much detail as possible about the examination as the records will be the key point of reference in any subsequent legal claim. Patient recollections can be powerful and where there are good clinical notes this can rebut a conflicting account and indicate that the written information compiled at the time can be relied on as sound evidence.
The key take away
Spending a little more time on record keeping will inevitably be more time consuming in the short term but will save on potential difficulties further down the line. Contemporaneous, clear, concise and complete dental records benefit both the dentist and the patient in encapsulating what happened at the consultation, including the factual information supplied by the patient, the status of their dentition and professional advice conveyed by the practitioner.
DWF's national healthcare team acts on behalf of a large number of clients, from individual insureds, insurers, private hospitals, the Medical Protection Society, NHS Resolution and a number of NHS Trusts. Our specialist team, led by Vicki Swanton, is on hand to assist with all possible challenges including complaints, regulatory, disciplinary, criminal or coronial investigations.
Written by Sabrina Mahmood - Solicitor
