Society is increasingly litigious and good record keeping makes a huge contribution to quality patient care as well as providing potentially vital evidence of discussions, explanations and clinical care and treatment provided.
The programme starts by explaining the nature and fallability of memory, and why we need to keep records that can compensate for these deficiencies. Judges and tribunals alike will often be persuaded by the word of the patient if there is any doubt over the facts of a case, on the premise that the patient is likely to recall the experience with more certainty than the dentist, who will have seen numerous patients on and since that particular day.
Comprehensive patient records can make the difference between success and failure in the event of a clinical audit, assessment of performance, complaint or legal action.
'On the Record' explores and demonstrates where, why and how patient records fit into good dental practice, using an engaging mix of theory, concepts and practical examples. It aims to provide you and your team members with some new insights into the role of record keeping, and the advantages and risks of electronic vs paper records.
About This Programme
'On the Record' is a 60 minute interactive programme which takes a detailed look at record keeping in dentistry and demonstrates how comprehensive and accurate record keeping can:
- Facilitate the monitoring and tracking of patient treatment
- Improve patient-centred care and reduce risk
- Provide a basis for professional development in practice
- Be used to demonstrate and audit clinical performance.
The programme consists of five 10-15 minute topics:
- Why Keep Records?
- Principles of Record Keeping
- Personalised Records
- Records and the Dental Team
- The Changing Face of Records
Topic 1: Why Keep Records?
This topic focuses on:
- The purpose of record keeping
- The nature of memory and its limitations
- How good record keeping can improve patient care.
Topic 2: Principles of Record Keeping
This topic focuses on:
- The requirements of a patient record
- The importance of being able to track treatment and its effectiveness over time
The importance of patient records that are:
- meaningful
- intelligible
- chronological
- contemporaneous
Topic 3: Personalised Records
This topic focuses on:
- The content of the patient record – both clinical and non-clinical
- How it will differ according to the individual patient and the treatment being provided
- How the context of an interaction influences the necessary content of a record
- The evolving and changing nature of record keeping
Topic 4: Records and the Dental Team
This topic focuses on:
- The implications and limitations of single authorship of patient records and how these can be overcome
- The advantages of delegating record authorship to other members of the dental team
- How all members of the dental team can be integrated into the record keeping process
Topic 5: The Changing Face of Records
This topic focuses on:
- The relative advantages and limitations of patient records in their various formats
- The role of records in clinical audit
- Confidentiality and data protection
- The dangers of falsified records