Auto-templates are often used by dental practitioners to increase the efficiency of their dental records. However, they can lead to inaccuracies. Dr Annalene Weston, Dentolegal Consultant at Dental Protection, considers the consequences
Mrs C attended Mr A, an OHT, for an assessment of her periodontal health. Examination revealed generalised pocketing between 3.5 and 5.5mm, with no great pockets. Mrs C had generalised sub gingival calculus deposits, particularly interdentally, and significant bleeding on probing around her lower premolar teeth.
Mr A advised Mrs C of his findings and explained the nature of periodontal disease. He advised she would require debridement over multiple appointments and offered her LA to make the treatment more comfortable.
Mrs C agreed to this, but also requested that Mr A “clean her teeth” on that day, as she had a wedding coming up, and was conscious of her staining and bad breath. Mr A agreed, and undertook a general debridement, not focusing on the sub gingival deposits, but ensuring that the teeth “looked good”. Mr A requested the reception team issue Mrs C with an appointment and an estimate. She declined both at the front office.
Regretfully, Mr A did not have time to complete his records at the time, intending to come back later in the day, as he was now running very late. At the end of what had been an arduous day, regretfully it slipped his mind, which meant that the auto-template note was entered as follows:
114: ultrasonic and hand. Prophy.
This meant that Mr A’s assessment was not documented and that critical discussions with Mrs C were missing.
Listed, in no particular order of importance, the records that are missing:
• The reason for attendance
• The patient’s symptoms
• The special tests undertaken
• Mr A’s conversations regarding Mrs C’s periodontal health
• The CPITN or probing depths
• The diagnosis
• The treatment plan, including the possible need for LA
Mrs C went to see another practice around a week later, to enquire about in-office whitening as she wanted her teeth to be as white as possible before the wedding. They undertook a comprehensive examination and advised Mrs C of the presence of sub gingival calculus deposits. Mrs C had either forgotten that she needed to come back to have the scaling completed, or perhaps never truly understood at the time. The discovery that her “teeth hadn’t been cleaned properly” and the new practitioner’s reaction to the fact that Mrs C’s had “just had a clean” and yet still had so much left to do, prompted her to complain to the regulator.
On this occasion, the regulator chose to meet with Mr A to talk through their concerns. They were clear with him that the reason they were considering disciplinary action, was the seeming inaccuracy of his records. In the absence of accurate notes reflecting what actually happened, Mr A could not defend himself against Mrs C’s allegations that he had not assessed her properly, that he had failed to advise her she needed to return to complete the debridement, and that he had discussed her periodontal condition with her at all. His records gave the appearance he had not assessed her or spoken with her, and that he had provided her with inappropriate care.
Pleasingly, the regulator accepted that Mr A had undertaken an appropriate assessment and that he had been denied the opportunity to complete the treatment he had planned – he just couldn’t prove it with his notes on the day. They counselled him regarding accurate record-keeping in the future and scheduled a record-keeping audit three months later to ensure that he was meeting the required standard, every time.
Learning points
- While they can increase our efficiency, auto-templated records must be modified for each patient to accurately reflect the unique circumstances of their treatment.
- Inaccurate or inadequate records do not enable continuity of patient care, as the next practitioner is not party to what really happened on the day.
- Inaccurate records impact on our ability to defend ourselves against allegations.
- Inaccurate records reflect poorly on our professionalism, as we are breaching the standard required by our regulator.
- You can check how your records stack up using this self-reflective tool: www.dentalboard.gov.au/Codes-Guidelines/Dental-records.aspx