In any dental role you have to provide the best care possible, but this can only be done with the right information. Having an accurate system of record keeping is crucial when it comes to clinical decision making – providing a reliable account of the patient’s history. It is integral so that all staff members are kept in the loop and that you are able to call upon details if your care is challenged down the line.
If you are wondering what the importance of record keeping is and how to implement your own system, follow our advice below.
Why is record keeping important?
Record keeping is essential as it supports your decision making in the dental care you provide, offering evidence as to why you did so. The records offer an overlook of a patient’s history, which can assist those who may take over as their dental provider in the future. Nobody’s memory is perfect, so having records to refer to is ideal.
The principles of good record keeping
Ensure your records are of a high standard by making sure they are:
- Legible and carefully written. You may find yourself in a hurry to write up your notes, but you must ensure they are clear and easy to read.
- All information is provided. Your notes should be a complete and accurate reflection of your appointment or consultation. Make sure to include all relevant information.
- Written accurately with a fresh mind. Try to write up your record as soon as you can after meeting with your patient to ensure you remember all of the details.
- Done in a timely manner. As well as being fresh, noting down details as soon as possible ensures the record is available when a member of staff needs the records.
- Written professionally with no personal comments. Do not be tempted to use obscure abbreviations, colloquial language or too much jargon, as a patient can request to see them. This, alongside making comedic or unprofessional notes, could damage your credibility.
- Dated and detailed. Not only will this ensure your records are more organised, but it will allow you to keep track of the timeline of someone’s treatment.
- Organised and filed. There is little point keeping a record if you are going to lose track of them. Find a system that works for you, but make sure each patient’s file is clearly labelled and easily accessible.
Recording an appointment or consultation
When it comes to record keeping, make sure your patients’ records include the following:
- Both normal and abnormal examination findings
- The diagnostic process should treatment be required, including how you decided this was the best course of action
- Patient history and previous dental records
- How decisions were made and then agreed upon
- Following the above, how this was discussed with the patient including potential risks and treatments available
- Any patient concerns or necessary preferences, particularly before treatment and when discussing their symptoms
- Advice and prescriptions offered
As mentioned, you should date all of your records so you can quickly find the necessary files as and when required – either by you or a third party. Please ensure that all of the files are assigned to the right patient, especially when you have some that have a similar name.
Other records to keep on file
While face-to-face appointments may be the first that spring to mind, there are a number of patient interactions that you should keep a note of. This includes the following:
- Telephone appointments
- Photographs or X-Rays with information regarding their importance
- Referral letters
- Discussions with colleagues regarding the patient’s care
By keeping such detailed notes, you can provide the best quality care and provide your best judgement. Should you need further advice about keeping on top of your record keeping, get in touch with DDS. We will be happy to help.