A patient attended a dental clinic for a tooth extraction. The GDP, Mr K, commenced what appeared to be a routine extraction of an Upper Right 7, but encountered difficulties when he discovered the tooth was fused to an unerupted Upper Right 8. He explained the position fully to the patient, completed the necessary surgical procedure and wrote up his records. Unfortunately, the patient developed post-extraction haemorrhage and attended the local accident and emergency unit. For whatever reason, the service was not ideal and the patient was transferred to a specialist oral surgery unit at a different hospital. Regrettably all this took time, in the middle of the night, and the patient felt that the initial responsibility lay with the GDP. This prompted her to send a complaint to the General Dental Council in regard to Mr K's standard of treatment.
Analysis and outcome
When the complaint arrived at the surgery Mr K took advice from the MDDUS and an appropriate response was sent to the GDC, including the records and radiographs. Mr K had computerised the records in his practice approximately one year earlier. Notes of the treatment on computer were fair but did not elaborate in detail about the surgical technique. It turned out that Mr K was not an enthusiastic typist and, in situations like this, would supplement the computerised records with handwritten notes. These were also sent to the GDC.
In due course, a response was received from the GDC indicating they would be taking no further action in respect of the complaint by the patient. However, they wished to clarify the timing of the writing of the dental records. From examination of the actual card, the coding indicated that this card had been printed after the date of the record entry. Mr K was asked to comment. The dentist then sent us the original handwritten record, which he claimed had been made at the time of the operative procedure. He had prepared a new copy of this for submission to the GDC as he felt it would be more legible. Regrettably, in comparing his 'transcript' with the 'original' there was some embellishment.
On further review, the Investigating Committee at the GDC was highly critical of Mr K's actions. They felt that the additional information contained in the 'transcript' was certainly not contemporaneous and a serious view was taken. It was recommended that the dentist should not run two separate record systems. Advice was also offered with regard to contemporaneous writing of records and fullness of notes.
It would certainly not be appropriate to discourage a dentist from writing full notes. It is appreciated that this can take time and if the task cannot be delegated, then the dentist should take the time to provide a full record. If such a record is handwritten and supplements computer records then, although not ideal to run two separate systems, it would be necessary to refer, in each set of notes, to the fact that another record also exists.
- Take to time to write full and comprehensive notes.
- Ensure notes are contemporaneous.
- Avoid having two separate record systems but ensure cross-referencing if unavoidable.