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Aim: To provide a guide to record-keeping and the surrounding ethical issues.

Objectives:

  • To help dental professionals understand what constitutes effective record-keeping.
  • To provide a comprehensive guide to the dento-legal issues that can arise when storing, sharing and disposing of patient records.

Anticipated learning outcome: To be aware of current guidance and best practice concerning record-keeping.

It is anticipated that this will help to meet the GDC development outcomes A and D.

The function of records

The main purpose of a dental record is to provide a complete and accurate account of the patient's oral health and ongoing treatment, to support continuity of care and minimise the risk of an adverse incident. Records are an essential resource for the treating dental professional - no one's memory is infallible - and for others who might be involved in the care of the patient.

Good record-keeping is an ethical, contractual and regulatory obligation. In Standards for the Dental Team, the GDC expects all dental professionals to 'make and keep contemporaneous complete and accurate patient records' and inadequate record-keeping is regularly cited as evidence of poor performance in fitness to practise hearings.

Meanwhile, Part 13 of the model NHS dental contract requires that, 'The Contractor shall ensure that a full, accurate and contemporaneous record is kept in the patient record in respect of the care and treatment given to each patient under the Contract.'

The Care Quality Commission (CQC), which oversees dental providers in England, states: 'One of the fundamental criteria used to manage risk in a dental practice is keeping good quality clinical records'. CQC inspectors may want to review practice protocols for completing dental health records, and have powers to access dental records to check they are 'accurate, complete, legible, up to date, stored and shared appropriately.'

And finally, records have a valuable dento-legal purpose if a dental professional's standard of care is called into question. In the DDU's experience, a contemporaneous record of a thorough examination or consent discussion can provide valuable evidence when defending a member against allegations of clinical negligence. Conversely, if you are accused of negligence, inadequate records may make it difficult to successfully defend yourself.

What makes a good record?

There is no shortage of professional guidance available on record-keeping, such as the FGDP's reference guide and the GDC's Standards for the Dental Team. But to keep things simple, try thinking in terms of the 4 Cs.

1- Contemporaneous: make a record as soon as possible after a patient interaction.

2 - Clear: record your findings carefully (and legibly if not using a computer) so that they can be understood by anyone who may need to read and interpret them. For example, avoid abbreviations as far as possible and use one system of dental charting. It should be clear who made an entry and when.

3 - Complete: record as much detail as possible of all relevant aspects of a patient's appointment, including:

  • medical history
  • dental charting and BPE scores
  • findings on examination including negative findings (eg no teeth tender to percussion)
  • diagnosis
  • discussions about treatment options and risks
  • agreed treatment plan
  • consent to treatment
  • treatment given
  • mishaps and complications.

As well as consultations, you should record telephone and email interactions with patients and any information relevant to their care, including radiographs, consent forms, photographs, models, audio or visual recordings of consultations, laboratory prescriptions, referral letters and test results. The exception is complaints correspondence, which should be kept separately because it is not directly relevant to the patient's clinical care.

4 - Concise: records should be just long enough to convey the essential information. Avoid superfluous personal comments that could backfire if someone else needs to access the record.

Gaps in the records

This scenario, based on cases from the DDU's files, shows how poor record-keeping can compromise patient care and make it difficult to counter allegations of negligence.

When a dentist decided to retire, the practice reallocated his patients to other members of the practice. Shortly afterwards, one reported that her former colleague had not been monitoring patients' periodontal health. While a number had advanced periodontal disease, she could find no record of their BPE scores and the dentist had not previously documented details of calculus, gingival bleeding or noted the advice he had given.

The practice contacted the dentist who said that it wasn't his practice to record negative findings or BPE scores if they weren't a cause for concern or to make a note of routine advice.

The patients concerned were horrified to discover that they required extensive treatment to stabilise their condition, with one later making a successful claim against the dentist after losing several teeth.