KEEPING clear, accurate and contemporaneous dental records is key to avoiding professional difficulties, MDDUS has said.
The UK-wide defence organisation has issued a new year call to dentists to cut out bad habits. Chief among those is poor record keeping which accounts for a large number of cases and calls from members.
MDDUS dental adviser Claire Renton has said that taking the time to ensure records are kept up-to-date can be “invaluable” for dentists who receive a patient complaint.
She said: “It’s fair to say that if it’s not in the records, then the assumption is you didn’t do it. 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.”
Mrs Renton has advised dentists to always note down what is discussed with the patient, particularly when the treatment is complex or expensive. Records should also note the treatment options discussed and any warnings 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 the notes.
She said: “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 practitioners may not be able to prevent complaints or claims being intimated, good notes can minimise the repercussions.
She added: “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.”
Dentists in any doubt about the requirements of good note keeping should contact their dental defence organisation for assistance and guidance.