On the record

NO DOUBT you will have been told many times of the importance of clear clinical notes, detailing the treatment given to patients. There is nothing new in this advice. But what has changed over the last decade is the requirement for increasingly more comprehensive notes.

Many older practitioners have not embraced this development and continue to write more minimal notes. This practice can leave dentists particularly vulnerable when facing a complaint to the GDC, a counter fraud investigation or a civil claim.

Don’t think that “it will never happen to me”. Very few dental practitioners will be immune from some form of complaint or claim in their career. Our case load at MDDUS has grown steadily over the last few years, particularly in relation to GDC investigations. And this can happen to more experienced dentists just as easily as those embarking on their career. Any complaint is costly in terms of time, reputation and the anxiety it causes. Best avoided if at all possible!

A good defence

Whilst you may not be able to prevent a claim or complaint being intimated by a patient, you can minimise the repercussions by taking good notes. A claim or complaint can be intimated many years after the treatment in question was provided. Civil claims are timebarred three years from the date of the negligent act or from the date that the patient becomes aware that there has been negligence. You would be surprised how many patients do delay in raising a claim many years after the event. It is highly improbable that in a busy practice you would remember a root canal treatment that you undertook that long ago. Remember the adage: “If it wasn’t written down, it wasn’t done”.

In court a dispute in relation to treatment provided becomes an issue of credibility. Whose version will the court prefer? If the clinical notes do not record the justification for the treatment provided or the options discussed, litigation then becomes an even riskier proposition. Many claims have to be settled because the fundamental basics are just not present in the notes.

Patient notes are your responsibility and yours alone. It is simply not good enough to say that you are working in a busy NHS practice and did not have sufficient time to write full notes or that the other dentists in the practice write short notes and therefore your practice has to adapt. Worse still is to blame your nurse. The court or the GDC will be unimpressed by such excuses. Your role is to provide a consistently high standard of record keeping.

The GDC publication Standards for Dental Professionals sets out the principals and clinical standards to be followed. In paragraph 1.4, the guidance states:

“Make and keep accurate and complete patient records, including a medical history, at the time you treat them. Make sure the patients have easy access to their records.”

The Faculty of General Dental Practice (UK) has published a guidance document for the standards of record keeping entitled Clinical Examination and Record Keeping (2009). This comprehensive guide provides specific and detailed information on record keeping and examination, and recommendations for audit.

If you are in any doubt at all about the requirements in relation to contemporaneous notes, then you should contact MDDUS for assistance and guidance. Below are some important do’s and don’ts.

Do’s

• Establish a good relationship with your nurse if she records your notes whilst you dictate them. Always check the notes and add your own additional observations if required.

• Identify the note as yours either by initials or by your signature if it is handwritten.

• Record all treatment provided, the taking of consent, warnings given about oral hygiene, advice about treatment options and positive and negative findings.

• Use only universally agreed dental abbreviations.

• Remember that negative results may be as important as positive ones.

• Be sure to identify other contacts cited in notes (consultant, nurse, relative, etc).

• When drawing up a treatment plan, ensure that it is revised, document changes and review regularly. When taking an X-ray, note the reason why, the result reported upon and any differential diagnosis.

• The dental history should be reviewed regularly and updated. This forms part of the dental record and should be accessible.

• Audit your records regularly to prove that your note taking remains up to a certain standard. Take advice on how to take audit effectively. Such guidance can be obtained on the NES website and in the FGDP(UK) guidance referred to above.

• Ensure your notes can justify the claims made. For example, when claiming for an extended scaling, record a BPE having been carried out.

• When using local anaesthetic, ensure that the type, dose and batch number are recorded and, in particular, ensure that the use of local anaesthetic is recorded when fillings are provided.

• Ensure notes use neutral language and are in no way derogatory—patients or families have access.

Don’ts

• Do not write in pencil as this raises suspicion of improper practice or claims. Always use ink or a ball point pen in a colour which can be scanned or photocopied.

• Do not obliterate any record. If altering a record, put a single line through it and initial it.

• Do not re-write notes at a later date: this includes additions to the contemporaneous notes. If there is a requirement for an additional note, this should be made as a separate entry and dated, timed and crossreferenced to the original entry.

From the perspective of MDDUS, the availability of good accurate records will substantially assist our ability to put forward a good defence either to a civil claim or to a complaint to the GDC. But more importantly, good notes are fundamental to good patient care. Notes allow essential communication with other dentists who may be required to continue your treatment. Poor records are normally indicative of poor and sloppy management.

Taking the time now to read the available guidance and to ensure you start your career with a high standard of note taking could save heartache in the future.

Lindsey McGregor is a solicitor at MDDUS

Case study

A dental patient lodges a claim after having suffered nerve damage during an implant procedure. She states that she would have chosen an alternative treatment had she known of the risk (damage results in lip numbness). The dentist claims that he informed the patient of the risk and other treatment options, but no record was made of these discussions in the patient notes.

Analysis: The dentist in this case would have difficulty in proving what was discussed without this having been recorded in the notes. The fact that the dentists did not record this discussion means the case would be difficult to defend in court.