CONSEQUENCES OF INADEQUATE RECORD KEEPING

Clinical
Conveying misinformation or omitting essential information such as the existence of allergies or medical conditions, recording inaccurate measurements, or failing to record specific treatments rendered can compromise treatment or endanger the life of the patient. If you have not kept adequate records you have failed to meet the standard of care.

Legal
If you fail to meet the required standard of care and cause injury to your patient you may be sued. If you are sued for negligence it will trigger your insurance deductible. It is inexpensive good practice to maintain accurate dental records.

Who Owns Dental Records?
In a recent decision, the Supreme Court of Canada decided that medical records were the property of the medical practitioner. The records are held in trust for the patient by the doctor or dentist, and are under his or her care and control. Records are transferred or accessed only if the patient signs an authorization for their release.
Adult records must be kept for 10 years. The records of minors must be kept for 10 years after the child reaches the age of majority. In Ontario that is 19.
J.W.

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There are some fundamental principles which should guide dental practitioners when record keeping. The following is a summary of the key issues to bear in mind when carrying out your record keeping duties.

What are Patient Records?

The Dental Chart and all of the measurements and tools used to gather dental information constitutes the Patient Record. These include:

-the written chart including a complete medical/dental history;
-radiographs;
-study models, cephlographs, drawings, photos;
-consents signed, dated and witnessed;
-standing or specific patient orders;
-the patient diagnosis, treatment plan and alternate treatments; and
-any referral letters or notes;

What is the Purpose of Maintaining Dental Records?

Dental Records serve two functions.

1. CLINICAL

a. The primary purpose is to maintain a proper standard of care and treatment;
b. Records serve as a reminder to treating personnel of the past condition and treatment rendered;
c. They advise of the treatment that others have performed;
d. They form the basis for future care and treatment; and
e. They provide recommendations for treatment.

2. LEGAL

In the event that a malpractice action or a complaint is initiated, without adequate, accurate, complete and contemporaneous records it is impossible to properly defend against and action of negligence or professional misconduct. Records are admissible in a court of law as business records if they meet these requirements. The patient is entitled as a legal right to have good records maintained. YOU CANNOT REPLY UPON YOUR MEMORY, IT BECOMES YOUR WORK AND MEMORY AGAINST THAT OF THE PATIENT.

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Little Things That Count

Most patients are not knowledgeable enough concerning dentistry to judge a dentist's "practice of dentistry" but they can and will judge a dentist on his or her interpersonal skills and those of the people representing him or her in his practice.

It will come as no surprise that the majority of patients who have sued their dentists have stated: " I would never have sued my dentist if he/she would only have:

• Been honest
• Said they were sorry
• Listened to me
• Acted like they cared
• Any of the above

One key to a successful dental practice is clear and understandable communication. Those dentists who take the extra time telling their patients what to expect are least likely to be sued.

Communication is Key

Studies have shown that a practitioner who spent an average 18 minutes with patients were less likely to be sued vs. those who spent 15 minutes. Those who were not sued also were more likely to use humour, to tell patients what to expect and to give patients a chance to ask questions.

What are the most frequently perceived problems by patients concerning dentist communication?

• Interruptions when I am talking
• Talking down to me
• Thinking I understand what has been said
• Acting like they are in a hurry
• Not listening

Pay Attention!

A body language and mannerism check list to consider after your next patient

Suggestions for more open communication with patients:

• Pay attention to non-verbal behaviours
• Avoid medical jargon
• Do not criticize other's performance
• NEVER guarantee an outcome
• Treat all patients courteously and with respect
• Be considerate of their time, comfort and privacy
• Return calls as soon as possible
• Present a professional image and provide patients with a positive environment
• Address complaints and concerns

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THE "3 C'S" - PREVENTION OF LAW SUITS AND COMPLAINTS TO YOUR GOVERNING OR LICENSING BODY

COMMUNICATION, COURTESTY, COMPETENCY not necessarily in that order!

Many lawsuits and most complaints can be avoided if you practice:

JOYCE'S DO'S AND DONTS for generalists and implantologists

Know your own abilities, and limitations, CLINICALLY AND PERSONALLY.

1. Seek help and confer with your colleagues if you are at all concerned with the proposed treatment or cannot quickly resolve a treatment problem.
2. Don't bring your personal problems to the office.
3. Don't treat a patient if you stressed out or having difficulty remaining objective with the patient.
4. Assess the patient before you begin the proposed treatment. Use all reasonable / available diagnostic tools.
5. Don't proceed with treatment if the patient does not meet the minimum criteria for implants.
6. Be realistic about who is a good patient.
7. Establish a treatment plan. Provide treatment options and alternatives.
8. Provide materials risks.
9. Provide all proposed information personally to the patient do not delegate to staff members. You can use video's to supplement but not without reviewing the case with the patient.
10. Use communication techniques to confirm patient understands your explanation of treatment plan, risks etc. INFORMED CONSENT MUST BE MEANINGFUL NOT A SCIENTIFIC DISCOURSE OR PERFUNCTORY. It must be appropriate for the age, level of sophistication of the patient. Have a question and answer period.
11. Send the patient home with written materials have patient back to review with you.
12. Have the patient sign and date the specific consent you provided in detail in front of you.
13. Be patient!
14. Don't warrant or guarantee your work. i.e. you will be able to chew a New York tenderloin, corn on the cob, delicious apples when I'm through with you.
15. Once you establish a treatment plan, collaborate closely with the oral surgeon and or the prosthodontist, technician whomever is in your team.
16. Once you open the surgical site don't drastically deviate from the surgical stent without consulting the prosthodontist or dentist fabricating the prosthesis.
17. Don't get too cocky even if you think you did a great job. Words such as I'm such a genius, I'm, thrilled this is the best job I've done to date can come back to haunt you.
18. Be careful about providing a formal written refund policy for failed implants, if risks are properly outlined unnecessary.

Watch out for patients who present with any of the following characteristics or problems:

1. smokers
2. alcoholics
3. patients who have lost teeth without denture placement for a prolonged period of time
4. recently divorced or grieving patient
5. troubled patient
6. patient with low self esteem who wants implants primary for cosmetic reasons
7. medically compromised patient
8. the aged
9. patient's with insufficient bone to support stresses and forces of mastication or to anchor the implants

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