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The good news is that less than 1% of the treatment records you complete every year as an oral healthcare practitioner will be looked at by attorneys, by the HPCSA, or by Dental Protection when supporting and assisting you with a complaint or claim. At those odds I can understand why most would argue that they could be doing something better with their time than completing records that possibly serve little purpose other than to help them remember what they were planning to do at the patient’s next appointment.
Years ago, the banks probably felt the same way about completing monthly statements for folk who regularly left the statement in an envelope gathering dust. Then someone invents technology and along comes AI, and everyone creates and retains huge amounts of data and records. Professional people everywhere make and retain records, and to not do so is simply unprofessional.
I had been treating a woman in her early 40s for a few years. She had a very aggressive form of periodontitis. Her plaque control was decent, and I spent a lot of time helping her keep root surfaces as clean as possible. Despite my huge efforts she lost teeth and lost faith in me when she discovered coenzyme Q10. Her position was that I should have known about the anti-inflammatory benefits of CoQ10 and had I told her she would have used it and obviously retained all the teeth she lost. That was what she thought. I was pretty relaxed about her demand for compensation until Dental Protection asked to see my records. The information I had written in my records could show my adviser what I had done every time I saw this patient but that was all. I had no baseline charting and measurements of attachment loss. I couldn’t show how quickly the situation was deteriorating despite my efforts because I hadn’t bothered writing down what I measured. I couldn’t even prove that she had been given very detailed information about the condition and poor prognosis and that a referral was a waste of time. She was going to lose teeth no matter who treated her, yet I felt incredibly foolish because I had failed to do what professional people do. I made a deal with myself there and then that I was never going to be caught out again by poor-record keeping and I wasn’t.
If you talk to the folks who feel like they are wasting their time writing a record they will say something along the lines that they don’t make money with a pen in their hand. I used to agree but I don’t now because the payment of an examination under code 8109 includes a requirement to complete a chart and write up the record. Years ago, Lawrence Weed said: “You couldn’t separate the record from the treatment of the patient,” and he was correct. It just took me a little while to realise what he meant that the treatment couldn’t happen without the memory held in the record.
So fast forward now as AI comes to our rescue and transcribes everything into a record and we can do it without a pen in our hands. The reality is many practices have moved onto electronic records saved in a cloud with huge amounts of information being collected from our patients. A lot of the data collected is repetitive and occasionally irrelevant. When you have to look through the record for dentolegal purposes it can be difficult to find the information that really matters and tells the story of the patient journey. The funny thing is that while the technology has changed, the questions we need the record to answer have not.
Regardless of who or what is involved in creating the record, it should contain sufficient information to answer the following 12 questions:
The relevance of this question is important as the patient may disclose information that implies they were unhappy with the services they had previously received from another practitioner, were looking for a fresh start, looking for a specific service or had recently re-located.
The purpose of this question is to identify what the patient expects to happen at this appointment. Occasionally patients attend thinking their clinical issues will be resolved at this appointment. A patient presenting in pain may be expecting you to relieve them of that problem or re-fit the crown that has just decoronated. It’s about expectation management.
It’s mandatory for a medical history to be taken in full and updated at every opportunity
Many patients will turn up with an on-going clinical issue and it’s important to understand the history of the problem and how it was managed. The question also helps you identify any specific challenges such as problems with local anaesthesia/inability to tolerate rubber dam.
We want to see information about the hard tissues and the soft tissues. Also, a charting and evidence that a basic periodontal screening has been completed and acted on.
Without a tooth chart regularly updated, data from a periodontal screen, and soft tissue observations you leave yourself a hostage to fortune if you are accused of failing to see or observe pathology. A screen or confirmation that the soft tissues were healthy tends to suggest you did carry out a thorough observation and if you did it is important to record that you completed that activity.
Could be vitality tests, radiography, CBCT scans. It is helpful to note what was observed because it shows you have taken time to carefully check the images.
Occasionally teeth with acute symptoms can be difficult to identify and it is not unknown for a healthy pulp to be removed in error or for the wrong tooth to be removed. If your records can show that the clinical decision followed a logical analysis of all the information collected from the patient then we are in a much better position to defend your decision even if it turns out to have been incorrect.
There is a legal and ethical obligation to provide each patient with the range of options usually available to treat the problem you have diagnosed. If you don’t make a diagnosis and record it then it’s difficult to argue the patient was given the correct range of options.
Again, there is a legal and ethical obligation to provide every patient with information about the risks and benefits of each treatment option. Patients will often say that they would have chosen a different type of treatment or no treatment or treatment from a specialist if there is a material risk they would have chosen to avoid.
Again, there is a legal and ethical obligation to provide information about the fees you will charge regardless of whether they are covered by the patient’s medical scheme or not.
The creation of a treatment plan and appointment schedule saves time, improves efficiencies, and you are not relying on your memory at any point in the clinical journey. If you are off sick or on leave, then another colleague can step in quickly in your absence and know what has to be done.
This is fairly obvious. Often though details of local anaesthesia administered and prescription of meds is absent from records. You are dispensing or prescribing prescription only meds and it’s important there is a record of what was prescribed and the dose.
Not all of these questions need to be covered in a record but without the information it’s human nature for attorneys to prefer the patient’s version or narrative particularly where there is a poor clinical outcome and a complaint. As technology makes it easier to create records, we still have to make sure that whatever data is created it can still answer the questions we all expect a record to answer.
