It is extremely important for both dentist and patient to be aware of the patient’s current periodontal status. This means ensuring any problems have been identified and promptly diagnosed, the correct treatment has been implemented, and the outcome assessed.
With regard to treatment, it would be inappropriate for Dental Protection to provide guidelines, or advice, on any clinical management; however, we remind you of the need to remain up to date with current thinking. It may be helpful to review your current CPD, and if periodontal disease management has not recently been covered, look for an appropriate course or event.
Recognised bodies of opinion
A useful video is available on the British Society of Periodontology (BSP) website: The Sound of Periodontitis. As well as this video, the website has a wealth of information for both professionals and patients. In particular, the BSP recently produced The Good Practitioners Guide to Periodontology 2016, and this is a useful starting point to update your clinical knowledge and ensure that you are following best practice guidelines.
In the event of a claim for compensation, if it can be demonstrated the clinician has followed published advice from a recognised authority, such as the BSP, it is much easier to construct a defence.
As in all fi elds of dentistry, once good advice and treatment has been provided, the
key is to be able to refl ect this information in the clinical records. Making detailed records is oft en a challenge in busy clinical practice, but is essential for both patient management and as supporting evidence if you are ever challenged.
One helpful way of ensuring the salient information is recorded is by training your dental nurses to help in the process. With some training, and practice, dental nurses can be recording details of the conversations you are having with patients.
As well as being an efficient use of their time, you may also fi nd they record bits of information that would otherwise be forgotten. Of course, the responsibility for
the records is ultimately that of the treating clinician, and they must check they are happy with what has been recorded, and amend it accordingly; however, this is often
a much more time efficient method than all the records being made by the dentist or
hygienist.
Using autonotes and templates
An autonote is a set paragraph, or phrase, that is simply copied into the records. A template, on the other hand, is more of an aide memoir, typically consisting of a list
of headings that remind the clinician what information they should be recording. Both
aids can be very helpful in practice, but must be used with caution.
As a general rule, templates are more useful as, by their nature, they require the clinician to manually fill in the relevant information. Autonotes, on the other hand, are often criticised for not being patient-specific. A common example is an autonote containing information on smoking cessation included in the record of a non-smoker. Once such an anomaly has been identified, it is much easier for a patient, or their solicitor, to question the validity of the whole record. When used, clinicians must ensure the autonote is modified sufficiently to reflect the individual patient and individual appointment.
Involving the patient
As mentioned, it is extremely helpful to be able to demonstrate that a patient has been fully made aware of their diagnosis. This is particularly so in a condition such as periodontitis, where patient engagement and compliance is key to achieving successful outcomes. Unfortunately, there are often cases when the patient may well have been given good advice, but it is not evidenced in the records. It can then
be difficult to prove the dentist has acted correctly, or for the dentist to stand their ground when challenged.
Information leaflets can provide much of what the patient may need to know, or should be told. One of the main problems with information leaflets is that it is easy for a lawyer to argue that the patient did not understand the information contained, or did not fully read the leaflet. They may argue the patient did not receive nor fully understand the implications of their diagnosis. With this in mind, it may be helpful to follow up any advice sheet with a patient questionnaire. This will provide an ideal opportunity to demonstrate the patient has been given all the information and tools for them to take control of their
own disease.
Communicating with the patient
Following a diagnosis of periodontitis, any patient questionnaire you supply can, once completed, be included in the clinical records. It must also be documented which leaflets and questionnaires have been provided, and if the patient does not return the questionnaire, a record of this fact can usefully demonstrate a lack of co-operation and patient compliance. The same information can then be provided and revisited at a later date.
These techniques can help you reduce your risk of claims and complaints, and provide evidence you are managing periodontal conditions in your practice effectively. Once these measures have been implemented, it is a good idea to audit your patient base to ensure you are maintaining best practice. Audit is an important part of clinical
practice and aims to ensure you maintain high standards of care.