Given the busy lives of dental professionals, time-saving measures are largely very welcome. Automatic templates that record information in patients' notes are just one example, but if not used carefully they can lead to an inaccurate account of what happened at the appointment.
Automatic templates are drawn up by some practices to make it easier for dentists to record the routine advice they provide to patients after certain treatments, such as 'patient advised to be careful not to bite soft tissues' after an anaesthetic is provided. These templates are designed to save dentists' time when completing the records, but it's important they are amended to reflect the advice given to each individual patient.
Automatic entries could lead to the record being inaccurate, and the DDU has been notified of several incidents of the wrong information being taken down as a result. For example, 'crown checked' isn't appropriate after an onlay was fitted. Neither is 'patient warned not to bite tongue' after an anaesthetic into the upper jaw, or even 'patient warned about contraceptive pill' when a male patient is being provided with an antibiotic. These seem obvious in retrospect, but errors can slip in if due care and attention isn't paid.
If an identical entry is made in every record - for example, 'examination, medical history checked, bp recorded' at the start, or 'patient understood/agreed/happy' at the end - it can undermine the integrity of the whole record. This can make it difficult for the dentist to justify what information was actually provided to an individual patient if a complaint or claim arises.
Errors can slip in if due care and attention isn't paid.
In some cases, dentists enter automatic templates into the record in advance of future appointments. This is presumably to speed up the record keeping process and with the intention of amending the record to reflect the actual consultation. You might anticipate what treatment you are planning to provide at future consultations with patients, as part of their treatment plan, but it's important to only complete the record of the treatment provided and the discussion had with the patient at the time of the actual consultation.
In a busy practice, it's understandable that dentists want to be able to make records as quickly and conveniently as possible, but it is important that the accuracy and integrity of the records are maintained. While the use of automatic templates from drop down menus is not in itself wrong, it is crucial for safe patient care that records accurately reflect the individual advice provided to each patient. Inaccurate and/or repetitive entries may also cause difficulties in defending a case, where patient records could play a key role in the defence.
If you are planning to use automatic templates, it's important to tailor the entry to the individual patient. If the template is meant to be a memory aid to ensure patients are provided with all the relevant information, it might be more appropriate to have a checklist for the information to be provided before, during and after certain treatments, rather than an automatic entry for the records.
Bear in mind the following when completing patient records, both digital and manual:
- records must be contemporaneous, clear, concise, and complete, whether they're digital or manual.
- records must be individual to the patient and accurately reflect the nature of each appointment
- extra care should be taken when using automatic templates to make sure the correct information is selected
- if electronic records do need to be modified, the date and time of the modification should be recorded, along with who made the modification.
For dento-legal purposes, computer software should be capable of producing hard copies of records and radiographs, and of producing a full audit trail of record creation and modification.