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.