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Many records created by clinicians are written in haste under time-pressure, and they contain minimal detail. In reality this has nothing to do with a lack of skill, commitment or attention to detail. Record keeping can seem to be a little boring sometimes. It is often viewed by the clinician as an administrative chore that must be completed after the patient has left. Nothing, of course, could be further from the truth.

By contrast, records made by non-clinical personnel and other members of the clinical dental team are often of a far higher standard. They usually contain more of the relevant clinical details and frequently represent a more comprehensive account of an episode of treatment. It is difficult to know why this should be, especially when the importance of good record keeping is reinforced endlessly to dental students from the first day of their course. What happens, then, when the dentist graduates and enters the ‘real world’?

Busy people

Most clinicians will tell you that the problem relates to a shortage of time. Clinicians are busy people and they spend most of their time talking to patients and treating them. Record keeping is less fun perhaps, and just seems to get in the way? To make matters worse, if we are running late in a hectic appointment schedule, we need to catch up by saving time wherever we can. Record keeping may seem to be an obvious candidate for time saving because skimping here is often not viewed as being damaging to patients. In fact, this is a short-sighted and potentially dangerous view.

With integrated teamworking on the increase in many countries around the world, the barriers which once kept dentistry as the unique preserve of the dentist, are now beginning to come down. Increasingly, given that clinical activities are being transferred to the other members of the dental team, record keeping could so easily be another of those delegated tasks. From a risk management point of view;

• It allows the clinician more time with the patient
• It adds an extra layer of protection against omitting key pieces of information.
• It uses the available skills of every team member to maximum effect.
• It allows for the inclusion of a different perspective of key events

Is it the training in dental schools that inhibits the delegation of this task? Students are always told to complete their records at the end of treatment and may not have chairside assistance all of the time. So it becomes ingrained that they are the only people able to perform the task. So much so, some clinicians actively discourage reception or administrative staff from making an entry in the records, or allowing the dental nurse to write anything but the briefest of details, implying that it is in some way illegal or unacceptable.

Such a notion is a complete myth. There is nothing in the law or in the guidelines produced by any of the regulatory bodies around the world that even suggests that only the clinician may complete records. It is true that the clinician assumes ultimate responsibility for the record entry relating to any treatment that he or she did, and must therefore be satisfied with what others have written, but the authorship is irrelevant. An entry made by the receptionist when a patient cancels or fails an appointment is just as valid in the eyes of the law as that written by the clinician. It is a record of the patient’s care and treatment; the fuller it is, the better it is.

Using the dental nurse

Consider a new patient examination. On most occasions a great deal of information needs to be collected, assessed and recorded in order to ensure that the treatment plan subsequently fulfils the needs and wishes of the patient. The first part of this information-gathering exercise is usually undertaken in the reception area where pre-treatment questionnaires and medical history sheets are completed by a patient. This information is then made available to the dentist who asks questions to seek further details of any relevant history that has been disclosed. The dentist then undertakes a well-rehearsed clinical examination and assessment of all the oral tissues and the surrounding structures. Each aspect of this examination is usually performed in a standardised sequence (Extra oral examination, soft tissues, TMJ etc). Once the clinician and dental nurse are equally familiar with this sequence, the details of the dentist’s findings can be given verbally to the dental nurse as the examination progresses, and the information recorded as it happens.

 

Risk management advantages

• The clinician can ensure that no aspect of the examination is missed.
• The patient’s perception of the time taken and details of the examination is quite different to any equivalent, but silent procedure.
• The records are likely to be more detailed and comprehensive, recording negative findings as well as positive ones.

Similarly, when a dentist is discussing treatment with a patient, a dental nurse would probably be in the best position to make notes of the conversation, the questions that were asked and the responses made. The more detail that is recorded, particularly in relation to discussions, the more accurate and helpful the record becomes.

Some might suggest that the dental nurse has other duties to perform which could be undertaken during that period of discussion. That may not always be seen as the best use of their time, and the issue is one of priorities.

Once the appointment is over and the patient has left the surgery, it is a relatively simple matter for the clinician to check the record entry made by the nurse and make any additions or alterations that are required. The result is likely to be far superior to anything written by the clinician alone in the brief interval before the next patient.

There are other aspects of record keeping (and records in general) that can also be delegated. Making sure that the correct record card is available for the patient sounds fairly obvious; until there are two patients with the same name, similar ages and sex. The use of photographs on paper record cards is unusual, but is not uncommon for computerised records in a practice where digital photography is extensively used.

Receptionists and practice managers can record details of failed and cancelled appointments and appointments offered to the patient, but declined. If a practice has a policy of recording details of each and every telephone conversation with a patient, the potential for disputes about amended appointment times is eliminated. Reception staff can routinely check that a patient’s personal details are up to date and that there is always a current medical history available. If it needs updating, they can help the clinical team to ensure that this is done.

Record keeping is a team effort and should not be the sole preserve of a clinician. It is certainly worthwhile to see just how much can be delegated since a complete, detailed record is a safer record – irrespective of who writes it.


Based on an article featured in the Dental Protection 2007 Annual Review