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I am old enough and grey enough to be a ‘silver surfer’, this puts me in the age bracket of someone who still associates mice with furry animals that eat cheese and ‘bytes’ as a serious mis-spelling. However, in this cut-and-paste world even I am tempted by templates. In fact, I hold my hand up and say that I use templates in my clinical records. They save time and effort, they enable a nurse and myself to produce notes that are confluent and look professional – on the face of it. As with all things, though, there is an evil twin hidden away in the shadows. Templates are a dangerous short-cut that need to be travelled with care.
Rule 1. Never load a template with clinical information. It is so tempting to think “oh, I’ll remember to alter that, or over-write it, every time I use it”. The chances are, that a pre-loaded BPE score will get transferred from patient to patient. I’ve seen it happen time and again in records I review for court. It’s obvious and it gets found out!
Rule 2. Never leave comments in that are common to most patients. I’ve just completed a report following a patient complaint where the Examination template had “Told how to brush teeth better” in every check-up, even for those patients that scored perfect indices for oral hygiene. A lawyer picked this up and it invalidated every record that the practitioner wrote in.
Rule 3. Never leave an item on a template incomplete. If there was nothing to see, record a negative. If there was, record what you saw. A blank answer, leaves you vulnerable to action if there is a complaint.
Rule 4. Delete the line if you have not completed an action, an action recorded but not taken leaves you vulnerable too.
Rule 5. If there are several of you, create your own individual templates with obvious differences. This makes it look that you are writing your own notes! Everything, from the order of symptoms and physical findings to the approach you use to treat each patient, is more natural when utilizing your own methodology, thinking process, and words rather than someone else's.
Another reason to create your own template and to keep altering it is because the best dentistry comes from within you. Often, it is based on your personal experience, your individual style, and your own thinking process. As you know, dentistry is not only a science but also very much an art form. Therefore, a template cannot possibly take into account your individual uniqueness, not to mention the uniqueness of your patients. In fact, templates force you to constantly regulate your style of practice to that of a one-size-fits-all approach.
For these reasons, keep templates so simple that every time you fill one in you are having to think a bit. The best way to use a template is simply as an ‘aide memoire’, it should be just a list of reminders (just one word will do) to make sure you have been through an internal check-list of things to cover at an appointment.
Dr John Shapter – QCS Expert Dental Contributor