From Volume 41, Issue 4, May 2014 | Pages 338-340
Clinical and ethical risk management requires not only the correct treatment being provided, and appropriate consent obtained, but also good records of that treatment. This third article of the series describes the characteristics of good records and their role in helping to prevent the progression of complaints, General Dental Council (GDC) cases and legal claims.
It is often assumed that a good technical standard of dentistry, as well as appropriate consent and communication, is all that is required to prevent problems occurring. However, the third strand of risk management, good record-keeping, is also fundamental. Unfortunately, records are not always seen as a particularly attractive subject. The volume of clinical treatment being provided, as well as sheer patient numbers, can produce pressures by reducing the amount of time available to complete the clinical notes.
However, the GDC gives clear guidance1 confirming the obligation to create appropriate records for all patients, stating:
‘You must make and keep complete and accurate patient records, including an up-to-date medical history, each time that you treat patients.’
In addition, whilst good records do not in themselves provide any extra income or productivity, and will invariably take up some additional time, they are invaluable in preventing the progression of many complaints and claims. Legal claims for damages, in particular, are much more likely to be successfully defended if the records are good.
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