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:
- When the patient presents with a specific concern
- When a condition is observed that varies from normal
- 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.