If It’s not in the records, then it didn't happen


For immediate release: Wednesday, 16 January 2013

Keeping clear, accurate and contemporaneous dental records is key to dentists staying out of professional difficulties, advises UK-wide dental defence organisation MDDUS.

A new year offers people the ideal opportunity to replace bad habits which, for some dentists, means improving their note keeping in dental records. MDDUS dental adviser Claire Renton believes that taking the time to ensure records are kept up-to-date can be invaluable for dentists on the receiving end of a patient complaint.

“It’s fair to say that if it’s not in the records, then the assumption is you didn’t do it,” says Mrs Renton. “Memories fade and the only way to be sure of what you did and didn’t do is to write it down.

“It is vital dentists make time in their busy schedule to update their records. Good notes are important in recording the overall management of a patient and help improve patient safety. It can also be the cornerstone upon which defences are built against complaints and claims.

“Take a note of what you discussed with the patient, particularly if the treatment is complex or expensive. Record the treatment options you discussed and record what warnings you have given to the patient concerning likely prognosis of treatment. For example, if the treatment is available on the NHS but the patient opts for private treatment – clearly mark this in your notes.

“Make sure you record positive and relevant negative findings. If something does go wrong with any treatment, and occasionally they will, tell the patient and make a note in the records that they have been informed.”

Whilst you may not be able to prevent complaints or claims being intimated, you can minimise the repercussions by keeping good notes. “There can be a significant time lag before such issues arise and you will unlikely recall the consultation in full detail,” says Mrs Renton.

“It is common for civil cases to take a couple of years to come to court once an action is raised. In a litigious setting, notes are far more reliable than your memory. Would you really remember in detail a root canal treatment you carried out from three years ago?

“At MDDUS, we have to settle many claims because the fundamental basics are just not there. Records serve to demonstrate professional integrity and justify courses of actions in the treatment process.

“If you are in any doubt about the requirements in relation to contemporaneous notes, contact your dental defence organisation for assistance and guidance,” adds Mrs Renton.


For further information contact Richard Hendry on 0845 270 2034 or 07976 272266, or email rihendry@mddus.com.

Note to editors

MDDUS (The Medical and Dental Defence Union of Scotland) is a medical and dental defence organisation providing access to professional indemnity and expert medico- and dento-legal advice for doctors, dentists and other healthcare professionals throughout the UK. For further information on MDDUS go to www.mddus.com.

This page was correct at the time of publication. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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