In the rush and pressure of a busy dental clinic it is easy to consider that by delaying record keeping you can make time for treating patients. This is never a good idea- at best it’s a failure to meet record keeping Best Practice (techniques grounded in research proven to support high quality patient care) at worst a patient may come to harm as a result of poor record keeping.
Record Keeping for Patient Care
The GDC Standards for the Dental Team- Standard 4 expressly says that contemporaneous patient records must be kept. The concept of contemporaneous records is not universally understood by registered dental professionals- they are defined as an accurate record, made at the time, or as soon after the event as practicable. They are a record of relevant evidence which has been seen, heard or done, by the maker of the note.
Contemporaneous notes are more likely to be accurate, as the events will be fresh in the writer’s mind this means that the notes will be more credible if challenged. On any occasions when record keeping is delayed, it’s important to make notes as soon as practicable after the event; and include a note of the reasons that the records were written up at a later time.
At present many practices keep handwritten records although increasingly patient records and data are being created, maintained and stored in electronic formats. The Data Protection Act 1998 defines a health record as:
“Any electronic or paper information recorded about a person for the purpose of managing their healthcare” section 68 (1) (a)
The Range of Dental Records includes:
- Treatment plans;
- Hand written treatment records;
- Dentists and other members of the dental care team records;
- Letters to and from referral dentists;
- X-rays, pathology other laboratory records;
- Digital/electronic records;
- Patient records include traditional communications with the patient such as letters to and from the patient and other information and communications relating to the patient e.g.
- Emails;
- Videos;
- Text messages relating to the patient.
Quality Management Records
The core principles of quality management are based on continuous improvement. The ability to define and measure the quality of care is dependent on excellent record keeping, to enable managers to monitor, audit and review processes. Each practice activity should be defined in practice policy with procedures and working instructions. Unless record keeping is detailed and appropriate it is not possible to assess the extent to which practice polices have realised the outcomes stated in the ‘Policy Purpose’.
In many cases the quality management records kept are defined in legal codes, this in particular covers a range of Health and Safety requirements such and Risk Assessments and incident reports. Others will be ‘Best Practice’ such as Significant Risk Analysis and a range of personnel management records. The QCS system provides a range of record keeping formats linked to relevant policies. Whatever the purpose of the records, keeping them contemporaneously will add to their value and enable the record keeper to ensure that they are clear, detailed and relevant.
