The Importance of Record Keeping

News Published: 
14 February 2019

FGDP(UK) Dean, Ian Mills, examines the benefits of keeping thorough clinical records.

 

 

Patients attend our practices on a regular basis for a routine oral health assessment. They have an expectation that we will take a history, undertake an examination, provide a diagnosis, offer a range of treatment options and discuss the benefits and risks before embarking on treatment. This is a fundamental process which we all undertake on a routine basis, and in many ways is a more important aspect of the care than the treatment we provide. This process allows us to understand the patient’s needs and their concerns, and allows the opportunity to build rapport and establish a connection with the patient. This person-centred approach supports the delivery of high quality patient care and underpins the process of achieving valid consent which needs to be documented within our clinical records.  

There would seem to be a greater ‘churn’ of dentists within some practices, which undoubtedly leads to a loss of continuity of care. In such circumstances we need to rely on clinical notes as a record of the consultation, the decision making process and any discussions and treatment which took place. Again, this is an important aspect of the clinical record in terms of consent, but is also key in providing integrated care in order that another clinician could seamlessly ensure continuity.

From a patient perspective this can help to ensure conditions are consistently managed. I recently attended a workshop where a young patient attended who had been subject to extensive restorative treatment as a result of tooth wear. The transient nature of his student years had resulted in a lack of continuity of care with visits to various different dentists over a period of years. This lack of continuity would appear to have contributed to his delayed referral to see a restorative specialist, which was considered to have compromised the management of his condition.

In recent times, with the move towards a more litigious culture, records are used just as much for protection as they are patient benefit. Whilst this is a situation none of us relish, it does appear to be a necessary evil, and we do appear to be spending as much time at a keyboard as we do at the chairside. The Dental Working Hours survey published by the NHS in August 2018 highlighted that although dentists work longer hours than they did when the survey first started, the amount of time spent on clinical work has reduced.

The clinical record is a vitally important feature of the patient consultation. We need to ensure that we meet the accepted professional standards in clinical examination and record keeping in order that we can protect ourselves from litigation, but just as importantly provide continuity of care for our patients. As a profession we need to work together to find effective ways to ensure that clinical record keeping is delivered to a high standard, but that the process is manageable for all practitioners and does not detract from the time we are able to spend with our patients.

 

For further best practice guidlines about clinical record-keeping, you can access the FGDP(UK) guidance on Clinical Examination and Record-Keeping, a complete reference guide to record-keeping and examination, which is available in hard copy and online.