Saturday, 30 March 2013
Tariq Drabu Dentist Record Keeping Guidance
I write today to remind colleagues of the need to maintain high quality up to date dental records which in turn will promote high quality referrals and minimise the risk to patients from inaccurate and confusing referrals. Good quality record keeping promotes high standards of communication between colleagues.
I am prompted to do this following the incident reported this month where a patient who suffered four years of agony after a procedure to remove a tooth has accepted £50,000 compensation. Rehana Musa, 72, sued dentist Dr Piotr Pietruszczak after he failed to consult her medical history before pulling out her wisdom tooth in 2008. This led to severe complications due to the wound not healing and indeed Mrs Musa had to have part of her lower jaw removed.
As dentists and responsible health professionals we must do whatever we can to minimise human error and mistakes when we treat patients. Good accurate record keeping is important. Inaccurate and poor record keeping can and indeed does lead to devastating errors.
I am the lead clinician on the Heywood Middleton and Rochdale CATS service, an innovative scheme designed to deliver specialist dental services within a primary care environment and have been leading on this service for the past 8 years. I get referrals from all over the borough of Rochdale from colleagues asking me to undertake surgical procedures on their patients. I have noticed an increasing incidence of poor quality, and inaccurate referrals. Some of them are illegible, some have the wrong tooth to be extracted, say lower left instead of lower right. Often the medical history is incomplete. A complete and accurate medical history is vital bearing in mind the events suffered by Mrs Musa.
Many times pre-operative diagnostic tests such as x-rays of the tooth in question have not been done which sometimes makes me wonder how a referring dentist can have assessed the tooth as being suitable for surgery. On occasions up to 40% of the referrals that I receive are deficient in some way and have to be rejected and returned to the referring practitioner.
In order to improve the quality of record keeping and thereby minimise errors I would always advise the following six key points:
1. Dental records must be easily legible if handwritten and they must be contemporaneous – i.e. they must be written at the time not some hours or days later when one’s memory can cloud recollection of events.
2. Dental records must be of a consistent standard and must state facts and not opinion and must be accurate.
3. Paper records must be kept securely together and have the patient’s name and date of birth on each page.
4. Records must be arranged in chronological order – so one event logically follows another.
5. Records must be regularly audited and benchmarked against recognised national quality standards. I would recommend doing this every quarter.
6. Medical histories must be checked and updated every time a patient visits the practice and any changes noted down immediately.
Ultimately we are responsible for the care of a patient who is putting their trust in our hands. We must do whatever we can to earn and keep that trust. Good, accurate record keeping is an important step along this pathway of trust. Poor quality and inaccurate record keeping can lead to lead to a confusing state of affairs for patients and disastrous consequences.