Dr Tariq Drabu Dentist Record Keeping

The Manchester Evening News reported on 7th December that a patient has been awarded £9000 by Manchester Dental Hospital following the extraction of a wrong tooth.

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. If a prestigious institution such as Manchester Dental Hospital can make mistakes then we as front line dental practitioners must be ever more vigilant.

As 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 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. 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.

Here are some common tips guidance for accurate record keeping. 

1.

Dental records must be easily legible if handwritten and they must be contemporaneous – i.e. 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.

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.