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What tends to go wrong with dental records?

Having good dental records is not just important during a complaints process. Good dental records also assist in patient safety, continuity of care, communication, auditing and forensics. However, dental records tend to come into particular focus when a complaints process is initiated.

To frame this discussion, it is important we refresh how regulation works in our State and Country. Dental practitioners are registered and regulated by AHPRA. AHPRA has 15 National Boards and one of them is the Dental Board of Australia (DBA). They register dentists, students, dental specialists, dental therapists, dental hygienists, oral health therapists and dental prosthetists (collectively termed ‘dental practitioners’).

At the end of November each year, we re-register as dental practitioners and we complete a declaration that underpins our eligibility to be registered. Noteworthy is the declaration that we will comply with all relevant legislation, Board registration standards, codes and guidelines.

There are two key DBA documents that are relevant to dental records. The first one is a 25-page document titled the ‘Code of Conduct’ and the other is a 4-page document called the ‘Guidelines on Dental Records’. It is an expectation that these documents have been read by all registered Dental Practitioners as we specifically agree to comply with them each year.

The Dental Board of Australia policies and guidelines are published for the public to see, allowing a patient (or their legal representative) to quote these standards where deficiencies are identified. However, it is seldom the case that a patient will complain about records specifically. When a notification (complaint) occurs, it is examined by the Dental Council of NSW (DCNSW) and it is this which prompts a review of the records.

One of the first steps that a delegate of the regulator (DBA/ DCNSW) will take is to make a request to the Dental Practitioner to provide all records pertaining to that patient. This is where Practitioners can get into trouble. Around 75% of dental records submitted in relation to a complaint fall below an acceptable standard. Although the records are unlikely to be the sole source of the complaint, if they are found to be inadequate, this can contribute to a complaint being escalated to determine if the practitioner is meeting their record keeping obligations as a registered health practitioner under the DBA Guidelines.

Specific common deficiencies in dental records observed are failure to document a diagnosis and informed consent. Given that it is the role of the Dental Board to protect the public, a failure to identify a diagnosis and informed consent within the dental records may indicate that these key steps may not have occurred, which can attract obvious concern. Verbal recollections will seldom hold more credence than the written contemporaneous documentation. Conversely, the dental practitioner who has ensured adherence to the DBA Guidelines through whatever mechanism favoured (checklist, template or systematic recording process), will be well-positioned in consideration of the care and process undertaken.

DIAGNOSIS IN DENTAL RECORDS

A diagnosis may seem obvious to a dental practitioner based on the history recorded and results of further tests such as pulp vitality testing, however, the Dental Board of Australia Guidelines on Dental Records still specify that a diagnosis should be recorded ‘where relevant’. This may beg the question, when is it necessary to record a diagnosis? A study published in 2016 provided additional clarity about the standards expected by drawing on the consensus opinion of experts in this field. In this series of articles, we consider what constitutes a complete dental record. 

A diagnosis is a critical component of the dental record in any of the following circumstances: 

  1. When the patient presents with a specific concern
  2. When a condition is observed that varies from normal
  3. When any treatment is proposed

What if I am not sure what the diagnosis is at this stage? 

Prior to arranging for further diagnostic tests or interventions, a provisional diagnosis should be recorded. This would indicate the basis for your actions and subsequent refinement to come to a definitive diagnosis. For example, if denture candidiasis is suspected based on the characteristic presenting appearance, recording this as the provisional diagnosis as the basis for an anti-fungal diagnostic and palliative intervention would be likely to meet the standard expected. 

Tip: Even though the recorded diagnosis may be somewhat technical (for example, chronic apical periodontitis secondary to carious exposure), it is worth thinking about how a diagnosis can be explained in lay terms to a patient. This will depend on their personal context, however, this is critical in the consideration of valid consent. Does the patient truly understand their condition (diagnosis)? The following may prove helpful when trying to explain complicated dental diagnoses: 

– Making a list of alternatives lay-terms that most patients understand (such as spreading infection, bone loss, cavity/ hole)

– Analogies to more common everyday occurrences (for example, barnacles on a boat for subgingival calculus)

– Drawings and photographs 

Tip: Don’t forget to record any of the tools you use to establish consent in your notes.

Relevant history as part of dental records

The Dental Board of Australia Guidelines on Dental Records outlines the requirements for Dental Records in Australia. However, this document is brief, and in some cases, open to variance in interpretation. A study published in 2016 provided additional clarity about the standards expected by drawing on the consensus opinion of experts in this field. In this series of articles, we consider what constitutes a complete dental record. 

What should be included as part of a relevant history?

Recording a ‘relevant history’ is mandatory according to the Dental Board of Australia, but what should this include? A relevant history is a history provided by the patient, usually relating to the presenting complaint and/or reason for attendance. This should include:

·       When the patient first became aware of, or suspected the condition, and any events that corresponded with it starting

·       What the patient has been experiencing as a result of the condition

·       Whether the patient has experienced the condition before, and the outcome of prior experiences

·       Outcomes of any prior diagnostic/ management attempts (including patient self-management)

·       What aspects of the medical, dental or social history could be important in the presentation, or management of the condition

From a continuity of care perspective, this information will provide an important baseline of presenting characteristics to which changes in status (either due to intervention or the passing of time) can be compared. Articulating the ‘history of complaint’ in such a structured way can be a useful mediator through a mental diagnostic tree for the clinician to arrive at the most likely provisional diagnoses. This is an excellent foundation for any further diagnostic tests.

An example of why this may be relevant is that the history of the presenting complaint usually supports the diagnosis, and in some cases, is diagnostic in its own right. Therefore, if there becomes any question of whether the diagnosis or treatment were appropriate, the presenting complaint characteristics becomes important. 

A practical example of this may be in the situation of a patient having root canal treatment undertaken. If this treatment was to fail, and the patient didn’t feel it was necessary in the first place, the presenting complaint may form an important piece of evidence that justifies the diagnosis and supports other records (such as radiographs, sensibility tests, percussion tests). 

An example of a presenting complaint: 

T/A #17 (points) started 2/7 ago causing loss of sleep. Spontaneous aching. Abscess 1/12 ago felt similar. Paracetamol TID ineffective. Deep resto here approx.6/12 ago.

Tip: Recording of the presenting complaint may be assisted by a skilled and trained clinical assistant. Although the dental practitioner cannot delegate ultimate responsibility for the accuracy and completeness of the dental record, the dental team can contribute to the draft form of these notes so as to allow the clinician to focus on the conversation with the patient during the initial collection of information.

To complete the Dental Records online training, click here