Record keeping isn’t just a necessary evil, argues Stephen Hooper – it’s also your weapon when the going gets tough
I can anticipate your reaction on seeing the title: another missive about dental records?
I know, I know, you’ve heard it all before and, frankly, it’s probably getting a bit boring hearing people talk about General Dental Council (GDC) guidelines, Care Quality Commission (CQC) requirements and the need to document everything you do with your patients.
Alas, there are some truths behind the preaching, and whether we like it or not (in my profession, we also have to document everything we do, so I feel your pain), record keeping is not only a fundamental part of your job as a dentist, it is also quite often your first, last and, sometimes, only line of defence. Please excuse me almost quoting Will Smith there, but it’s true.
In nearly 15 years of representing dentists under investigation by the GDC, NHS England (or PCTs when they existed), the CQC, or those being sued for negligence, I can probably count on one hand the number of cases that didn’t include allegations of poor record keeping.
The process
When a complaint comes in from a patient, the first thing any organisation investigating will do is to get hold of the records.
When this happens, even the very best clinicians – including those who think their standard of record keeping is quite good – can find holes being picked in their practice once their records are put under the investigative microscope.
Often, once the investigator gets hold of the records, they will fire allegations at you that the patient would never have thought of.
For example, you might receive a (wholly unjustified) complaint from a patient about their root canal treatment, but when the investigator picks it up, they are less concerned about the endodontics and instead accuse you of not carrying out BPEs, and not grading or reporting on your radiographs.
‘But I always do BPEs, and why would I take a radiograph and not evaluate it?!’ you proclaim.
‘Well, if it’s not written down, it didn’t happen,’ says the GDC. ‘Plus we’ve now carried out an audit of 40 of your other records, and it appears to us you never undertake BPEs and your radiographic practice is, frankly, woeful’.
‘But I always do them, I swear!’ you cry out, in desperation. ‘Not so far as we can see,’ says the GDC. I could go on.
Although I have dramatised the dialogue for effect, this is all the more difficult because you will rarely have an actual conversation with the investigator.
More often, it will be dealt with in drawn-out, tedious correspondence that can feel like banging your head against a wall so hard and impenetrable, Donald Trump would be proud of it.
The guidance you have seen from the GDC, the CQC and your defence organisations is record keeping is a fundamental part of patient care.
That guidance is worth adhering to, for the following reasons:
• Your records can help you to reach your diagnosis and treatment plan
• They will help another dentist complete your patient’s treatment plan if you’re away from the practice
• They can document socioeconomic information about the patient that might help unearth wider problems (I can think of one case I worked on where the dental records revealed a pattern of domestic abuse – sadly, the patient’s gingivitis was the least of her problems)
• They serve as a reminder of underlying health issues that affect treatment plans (reference the former client who didn’t bother asking the patient to complete a medical history form, started treatment then found out the hard way that the patient was violently allergic to latex).
In addition to all of this, they are your first line of defence when that rambling, vitriolic and completely unfounded complaint comes in.
A memory game
A busy dentist might see 30 to 40 patients per day. There is simply no way you are going to remember everything you did, everything you said and everything you were told with every patient.
I have had cases with many dentists who tell me they always do the thing they have been accused of not doing: but what if this was the one occasion you had a bad day or didn’t have time to do it? If you write it down and your notes are contemporaneous, clear and fulsome, you will be 1-0 up when it comes to responding to the complaint.
The patient is unlikely to have written anything down and will be guided solely by their memory and in many cases, memories not only fade, but also cross-fertilise and conflate. You, by contrast, will have your trusty dental records to rely on.
The GDC, NHS England, a judge or anyone else looking at the case will usually start from the point of view that what is recorded in a contemporaneous note is likely to be a true and accurate account, and it will be for the complainant to prove that it isn’t.
That isn’t to say that a good record will always be the silver bullet we crave, but it is certainly much better to have it in your armoury than be without it.
I know this is easier said than done and the reality is that, in a busy practice, time is money and you only have a few minutes to elicit a history, plan, take consent and treat.
Some of us have a one-fingered typing style that makes entering detailed records an embarrassingly slow affair.
However, for the sake of your patients and your own self-preservation, if you know your record keeping isn’t quite up to standard (be honest with yourself: you know who you are), find a way to do something about it.
Some use templates; others get a member of the team (such as the nurse) to type as they dictate; the really committed will sign themselves up to a speed-typing course or invest in dictation/typing software.
Time investment
I have seen some really helpful guidance documents from defence organisations – read them, but apply them. Hopefully, you will never have to find out how useful a good record can be, but if you do, take it from me that you will be glad you invested that extra time to get it right.
Eastwoods Solicitors has a well-established reputation as a leading specialist healthcare defence firm. For more information, visit www.eastwoodslaw.co.uk
