As part of my job, I read a lot of clinical records in order to write reports on possible negligence or in defence of complaints. Some practitioners make this task really hard by not writing very much at all. In these circumstances I need to forensically drag something out of the notes that might give me a clue as to what actually happened at an appointment. In recent years there is a phrase which I have come to dread! This usually comes at the end of a record about an appointment and is where the practitioner is trying to leave the impression that everything went well and the patient had no problems and actually liked the denture/bridge/crown/filling that they went away with. This reads – “Patient Happy”
I am sorry to say that as a record this actually means very little, it certainly doesn`t hold any weight in a legal sense. To convey what a patient felt, or what they agreed with or didn`t like, we need to use a little more narrative. This might seem like a waste of time and effort, but is essential to protect yourself if there is a complaint. In a task of `process recording` we need to provide a little more meat on the skeleton. Where you want to leave evidence in the notes that someone was happy with a crown for instance, we might leave a note of their actions: “Mrs X looked in the mirror and smiled, she nodded her approval”. We certainly need to leave a record of what they said. “Mrs X said `That`s really nice`”. All evidence that can be called upon in the future.
If a patient isn`t forthcoming with lot`s of praise, it`s important to find out why. Better to ask a question and get an answer on the spot, than to get a letter of complaint through the post later. Record the process: “asked patient if it looked OK”. There are only two possible answers to this and they need to be recorded too: “Mrs X said it was a bit long” in which case you can record a response of your own, or: “Mrs X replied `It’s fine`” in which case you have a positive record.
These are only short phrases to type, but can save your life later. Please don`t just put `Patient happy`