Anatomy of a Good Dental Record
To assist members in creating and maintaining good records, RCDSO published revised Guidelines on Dental Recordkeeping in November 2019. Among other things, the Guidelines state that patient records must be accurate, comprehensive, legible and accessible. Entries should be dated and signed, initialed or otherwise attributable to the treating clinician. They should be typed, handwritten in ink or recorded in an acceptable electronic form.
The level of detail required for a record to meet RCDSO standards is patient-specific, but the following baseline information should always be included:
- Current general patient information (e.g. name, address, phone number, )
- Up-to-date medical and dental histories
- A description of the patient’s presenting conditions on initial examination
- Diagnosis and treatment options
- A detailed treatment plan
- Documented informed consent (e.g. notes of any discussions about the risks and benefits of the proposed treatment and, where appropriate, signed patient consent form)
- Notes of referrals to or consultations with other health practitioners
- A record of missed appointments and
Progress notes describing the treatment rendered to the patient should be completed for each visit and should contain:
- the date of treatment;
- a concise and complete description of all services provided;
- the treating clinician’s identity;
- the materials and methods used; and
- all recommendations, advice and any discussions regarding possible complications or
Health Records as Evidence
Since lawsuits may be started years after the treatment in issue was rendered, charts, notes and other records (e.g. radiographs) are often the best and most reliable evidence of what actually occurred. Both the plaintiff and the defence will rely on the records in assessing the merits of the case, proving their versions of events and obtaining expert input. A chart that complies with the RCDSO Guidelines can be useful in persuading a court that the dentist met the standard of care by properly assessing, diagnosing and treating the patient and/or by providing the patient with the information required to make an informed treatment decision. Conversely, a record that does not disclose the dentist’s findings and thought processes, or include and creates a credibility contest that is likely to be resolved in the patient’s favour.
But even the best records may be of limited assistance in defending a legal action if their integrity has been compromised. For example, a dentist may give original records or radiographs to a patient, who may lose, alter or destroy them, potentially impairing the dentist’s ability to mount a full defence to a complaint or claim brought by or on behalf of that patient. Since health records belong to the provider, patients should only be given copies. No patient should ever be left alone with an original chart.
Alterations to a patient record by the dentist may also make a case more challenging to defend. In order to avoid allegations of tampering, errors or incorrect information should never be erased or eliminated from the chart, but should rather be struck out in such a way that the original notation is still readable. Late entries should be clearly marked as such. In no circumstances should a member add to or correct a patient’s chart after receiving a demand for compensation or notice of legal proceedings relating to that patient. Any changes made against that backdrop would likely be seen as self-serving, perhaps even fraudulent, and could give rise to an award of punitive damages against the dentist.
Conclusion
Though sometimes time-consuming, keeping good records can be a dentist’s best defence to a claim of professional negligence or misconduct. Following these simple rules will enhance patient care and improve the dentist’s chances of prevailing in a legal action or College complaint.