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Those dreaded words…..
Every month, the General Dental Council news column hosts numerous examples of dentists being ‘struck off’. The news is dreadful; it is not just about an unhappy or damaged patient, but also the traumatised life of a fellow practitioner and possibly their family too. Quite often, this is the result of a slowly deteriorating commitment to professional standards leading to an ‘off day’ that is a disaster for all. The good news is that investigations by the GDC rarely end with this outcome. Even when a complaint is brought, even when it has some merit, the GDC are looking for evidence that it is a learning experience and will adjudicate accordingly.
Good record keeping, good record keeping, good record keeping
By far, the most common factor is poor record keeping. This might be because the complaint is actually concerning a lack of notes. It might be that records were misleading and even fictitious. It might simply be because good notes would have enabled a dentist to defend their actions.
Have a look at a couple of examples from a GDC report concerning the same dentist:
“2. Your record keeping in respect of Patient A was substandard in that you failed to keep any or any adequate records of the treatment provided, including extractions.”
“3. Your care and treatment of Patient B was substandard in that you issued a prescription for antibiotics without adequate clinical justification on 26 November 2010.
“4. Your record keeping in respect of Patient B was substandard in that on one or more occasions as set out in Schedule B you failed to adequately record:
(a) a medical history and/or update;
(b) a treatment plan;
(c) informed consent;
(d) the use of anaesthetic;
(e) your prescribing including an appropriate rationale for the prescription
(f) the care and treatment provided including steps leading up to the construction of partial dentures.”
What would a new dentist learn from your notes?
It seems like an onerous task, but we need to record what was said, what was done, what it was done with, why it was done and what the outcome was. This is not just to protect yourself, but concerns patient safety and continuity of care. Very simply, if you were run over by a bus today, what would a new dentist be able to learn from your notes concerning your patients?
Many of the Care Quality Commission Fundamental Standards have good record keeping as the foundation of good care. We need to be vigilant with ourselves and avoid laziness and complacency regarding clinical notes. I know it’s difficult during a busy day to keep on top of record keeping, but try to make it a rule that the next patient does not enter the surgery until the last notes have been written.
Write it down!!
Dr John Shapter – QCS Expert Dental Contributor