How does Covid-19 change my dental records?
How does COVID-19 Change My Dental Records?
In the wake of Covid-19, we have seen a surge in the demand for our dental records course. It is difficult to pinpoint exactly why this may be. Perhaps it’s a product of clinicians having more ‘down time’ on their hands during some of the restriction phases to undertake CPD, perhaps it’s a heightened awareness of risk and compliance? One question that we have been asked is, what extra things do I need to record when treating patients during this time of Covid-19 concerns?
Whilst record-keeping requirements remain essentially the same under the current Guidelines for Dental Records mandated by the Dental Board of Australia, the following suggestions may prove useful in the instance in which records need to be retrieved to determine the appropriateness of care during this period.
1. An up to date medical history: whilst the Guidelines on Dental Records indicates that an up to date medical history is required, the specific frequency with which this update should occur is less obvious. Research published in 2018 would indicate that this remains to be a contentious expectation. Other research prior would also indicate this is a frequently overlooked aspect of dental records. However, in the context of Covid-19 risk assessment, it appears more pertinent than ever to ensure protocols are in place to ensure the medical information on hand is up to date for every patient at each appointment. It would be difficult for a practitioner to determine the level of risk based on the current Covid-19 Case Definitions without information that is contemporary on the day of treatment. Some software providers have been fast to innovate in this regard and now have specific sections in their medical forms to update important aspects such as respiratory symptoms with ease. Regardless of the records system used, it seems pertinent to take a particularly diligent approach to contemporaneous medical history updates at this time.
1. Procedures undertaken: when working under restrictions, mandates or indeed professional guidance as an indication of peer expectations, it is important to record how you have taken this into account during any procedures undertaken. For instance, what pre-procedural mouthwash protocols have been used, was rubber dam used, were any normal work practices deferred due to particular patient risks (for instance, the use of hand instrumentation as an alternative)? All of this information helps to provide an overall picture of the risk assessment and precautions that were undertaken for each instance of care. Remember, if it isn’t recorded, it is likely to be assumed it didn’t happen.
Some helpful tips:
· Ensure you check any screening being undertaken by team members. Screening processes should not only be directed and overseen by the dentist, but should also be documented by the staff member performing the screening with their identity clearly noted, and checked by the treating clinician as needed.
· Set up templates to allow for ease of recording. Templates should always be customisable to reflect any aspects about the interaction which were unique (such as accompanying persons or risks disclosed), and should refer to the Case Definitions for appropriate risks to be assessed.
If you would like to learn more about dental record keeping compliance, please contact your Professional Association Branch to access their courses on this important aspect of practise.