Would your clinical notes stand up under scrutiny?

I have recently been approached by a number of dentists who have experienced patient complaints or feedback from their defense organization that has caused the dentist concerned to question the quality if their notes. Another dentist has also been asking questions about how to implement a record keeping audit.

I am sure that if any of use were to go back and audit our notes we would find that they could be improved. In this world of increased litigation, I am sure that you want to make sure that your notes give you as much protection as possible.

I have recently developed a full -day training that I run in-house with dental practices so that all members of the team understand what is required and their responsibility.

For those of you who follow my work will know that I use mnemonics to help you remember the frameworks, making it easier to implement.

The mnemonic for record keeping is CLEAR NOTES.

From this I would like to share with you a small part of the final S which reminds you to structure your notes.

Again, we have another mnemonic HEAD DROID

H = History. What is the history of your patients’ complaint, pain dental history, etc

E = Examination. When you do an extra oral and intra oral examination, what did you find that was normal and abnormal?

A = Aids to diagnosis. What further tests and special investigations did you do and what were the results?

D = Diagnosis.  What is your differential, provision or definitive diagnosis?

D = Discussion. What did you discuss with your patient, what questions did they ask, what was their understanding of the conversation,

R= Robust consent. Have you obtained consent following a robust process, more than just a signature?

O = Organise your treatment plan. Organise and document your treatment plan into number, order of appointments, including appointment length and intervals between appointments etc.

I = Implement. Implement your treatment plan so anyone wo looks at your notes knows precisely what was done, why any post-operative instructions and what is the next stage.

D = Double check. Make sure you have a system to make sure all actions such as referrals and other action points have been completed and nothing can fall through the cracks.

If you would like more information about how you and your team can use the CLEAR NOTES and HEAD DROID framework to ensure your notes are clear and safe, contact me on 07989757884 or email Jane@IODB.co.uk