Dental record keeping: what is professional, reasonable and in the interest of patients?

Are you spending a lot of your time taking copious notes and keeping records in meticulous detail? Do you feel like your time would be better spent with your patients?

The idea that dental professionals need to record everything in minute detail appears to be largely driven by apprehension about what might happen if complaint or claim is made, and the consequences if there is insufficient documentation to show what did happen during an appointment.  

We want to allay some of these concerns by explaining more about what is expected when keeping records, and the role clinical dental advisers play in fitness to practise. Shamir B. Mehta, Senior Clinical Dental Adviser, explains our pragmatic and proportionate approach to reviewing patient records.   

What is the role of clinical advisers in fitness to practise?

As set out in the Standards for the Dental Team, as dental professionals, we have an obligation to make and keep accurate, complete, legible and contemporaneous patient records. That does not mean records need to be comprehensive or that every single detail needs to be recorded, but they do need to be clear and complete. Let me explain.

Clinical records can:

• provide a clear account of the patient’s oral health
• aid diagnosis and treatment planning
• help prevent adverse incidents, and
• may prove pivotal when a complaint, concern or a claim is raised.

When a clinically related concern is raised, at an earlier stage of the process (assessment) a clinical adviser is usually instructed to determine if the standard of care has met the level of professional practice reasonably expected of a registrant working within the same discipline.

Clinical adviser investigations are usually based on the assessment of patient records and other items of correspondence, however, excluding clinical examination. Clinical advisers, like me, must carefully draw on their knowledge and experience of the matter and consider the circumstances, while at the same time refraining from opining against the ‘gold standard.’ The clinical adviser’s overall opinion may be influenced by appropriate authoritative guidance and the available professional standards.

What will clinical advisers be looking at and for?

Clinical advisers will usually consider the available documentation for:

• the pre-treatment aspects and the attainment of consent
• the treatment phase, and
• any aftercare provided.

While the clinical adviser’s opinion will be influenced by the type of appointment, any consequential level of criticism associated with a failure to meet the reasonably expected standards will be determined by the level of departure, and by the severity of any (potential) harm caused. It’s why the recording of an up-to-date medical history is essential when you treat a patient. Although there are circumstances when an appropriate socio-behavioural history and a past dental history should be undertaken and recorded, without evidence of clear risk of (potential) harm resulting from not doing so, the level of any criticism is likely to be much more tempered.

The patient’s reason for attendance and the history of their complaint should also be ascertained, and accurately and concisely recorded, in the least, to help you diagnose. Your notes should be comprehendible to others. Superfluous and voluminous documentation that lacks any further material importance is not expected, and to an extent, could be a misuse of precious resources and (clinical) time.

What do we look for when reviewing clinical records?

For the clinical examination, the outcomes and records should facilitate diagnosis and care planning, such as an appropriate extra-oral assessment to support the prescription of antimicrobial drugs for the (adjunctive) management of an acute dento-alveolar infection with evidence of pyrexia or a diffuse swelling.

Undertaking and recording of appropriate intra-oral soft tissue assessments, with oral cancer screening would usually be expected at each course of care given the importance of early detection and diagnosis, especially for infrequent attenders or higher risk patients.

Hard tissue charting and detailing periodontal probing screening outcomes (pending the nature of the appointment and presentation) may be relevant but using a numerical clinical index for the quantification of disease severity without recording any scores has limited merit. In relation to the charting (and risk assessment) for tooth wear and the recording of occlusal assessments, published research (see references below) has also reported higher levels of inconsistency. In most cases it would be unfair to be overly critical for failing to record these, unless of course, it was of material importance.

For radiographic practice, however, as per the Ionising Radiation (Medical Exposure) Regulations (IRMER) there are various responsibilities duty holders should meet, to include clinical evaluation with interpretation of the image and documentation of the findings.  

For a routine case in a general practice setting, it is ideal to record:

• a clear or differential diagnosis
• a logical treatment plan, and in the least
• risk assessment outcomes for dental caries, periodontal disease and oral cancer.

In the absence of an explicit record for these aspects, it may be difficult for the clinical adviser to be overly critical if it is clear that they:

• have been suitably undertaken and the outcomes can be determined from an otherwise satisfactory set of patient records
• the likely findings have been appropriately applied, and
• the care plan is supported by a written treatment plan.

Inform patients and record their consent, and be sure to check your notes

We have an obligation to obtain valid consent prior to starting treatment. Discussions to ensure patients can make informed decisions about their care needs should:

• be documented accurately and concisely
• include a record of any relevant alternatives and perhaps your recommended option
• provide clarification about the arrangements under which the care is available (NHS or private).

It is, of course, improper to record something that has not taken place. Diligence is also required with the effective use of auto-notes and record keeping templates, where inadequate use may risk raising some doubt about the credibility of the overall record. Documentation prepared by others in the dental team must also be carefully reviewed and finalised, clearly signed and dated.

The use of consent forms, without accompanying appropriate discussion and documentation may not properly support the attainment of valid consent. However, written consent must be obtained where treatment involves conscious sedation or general anaesthetic. In relation to any referrals, the clinical adviser will aim to verify your explanation of the referral process to the patient (which should be recorded), as well as reviewing any written prescriptions and correspondence given to a colleague, ensuring they have been given all the information they need.

With reference to any treatment provided, the clinical adviser will aim to appraise the available evidence to verify the adoption of a reasonable and logical approach to support the provision of good quality care, delivered in a safe and effective way. This may include any advice given, drugs prescribed, and the treatment execution (including post-operative instructions etc.). The clinical adviser will also normally consider the alternatives (such as the reasons for the premature failure of a restoration), as well as any specific challenges encountered, which you should record.

Make a record of any aftercare you provide

Occasionally, things do not go to plan with patient care. Aftercare provision, including any effective and constructive complaints resolution, being open and honest, and the offering of a timely apology, should be carefully documented, and appropriate aspects kept distinct from the main body of the records. These will demonstrate professionalism and that you are putting your patient’s interests first – fundamental aspects which are likely to have a bearing on the clinical adviser’s overall conclusion.  

Our team of clinical advisers have been applying this approach since 2017, and since then we have seen a reduction in the volume of single patient clinical concerns progressing beyond the earlier stages of a fitness to practise investigation (assessment), rarely progressing past the next stage (case examiners).  

Indeed, over the past five years, not only has there been an overall progressive reduction in the number of concerns reported, but the number of cases progressing to a substantive hearing has also gone down, while the number of professionals on the register has concomitantly increased.

We want to make sure only the most serious concerns are fully investigated through our fitness to practise processes. The initial inquiries pilot is helping us to achieve that goal and has now been extended until October this year. Success of the pilot hinges on the cooperation of dental professionals to make and keep appropriate patient records. Doing so will save you time and help us to conclude clinical cases as early as possible in the process.

Find out more about the extension of the initial inquires pilot.  

Or more on the trends we are seeing in Fitness to Practise from Clare Callan, Associate Director, Fitness to Practise.

References:

Mehta SB, Loomans BAC, Bronkhorst EM, Banerji S, Bartlett D. A study to investigate habits with tooth wear assessments among UK and non-UK dental practitioners. Br Dent J. 2020;228(6):429-434. 27 March 2020.

Mehta SB, Rizzo D, Paulose B, Botbol A, Vijay S, Arjuna A, Banerji S. Evaluation of dental practitioner habits with occlusal assessment and the clinical application of practical techniques in occlusion, amongst a cohort of participants based in the UK, South Africa, Malta and Malaysia. J Oral Rehabil. 27July 2022.