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Dental professionals are compelled by law and duty of care to produce and maintain adequate patient records. This review article discusses some of the salient features of good records, access to records, record retention, records in malpractice and the use of dental records in forensic identifications. With the increasing awareness amongst the general public of legal issues surrounding health care, and with the worrying rise in malpractice cases a thorough knowledge of dental record issues is essential for any practitioner – especially those who are just beginning their careers.
Note
that this document refers to the legal situation with England and Wales
only. If any visitor can provide details for North America -
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Introduction The
ability of clinical practitioners to produce and maintain good dental
records is essential to good quality patient care as well as being a
legal obligation. Unfortunately dental records are often unsatisfactory.
A study performed by two Regional Dental officers in the UK
identified charting as inaccurate in 38% of examined records and absent
in 14%, less than half (48%) were considered satisfactory [1].
In another observational study on the quality of dental records,
Swedish researchers found a large discrepancy in the quality of examined
records [2]. In the study
they examined ten years worth of patient records which had been
submitted for the purposes of forensic identification.
A startling statistic is that 10% of the patients were identified
incorrectly on their records! Other areas of concern included signatures
in only 5% of records and the documentation of a treatment plan in only
8%. These simple mistakes
can lead to errors of treatment, confusion when transferring records and
opens the practitioner to criticism should a medicolegal claim be made
against them. What is a patient record?
In
brief the patient’s record is the complete story of the history,
physical examination, diagnosis, treatment and care of a patient [3].
The record may consist of several different elements; common ones
include written notes, radiographs, study models, referral letters,
consultants’ reports, clinical photographs, results of special
investigations, drug prescriptions, laboratory prescriptions, patient
identification information and comprehensive medical history.
Clearly this is a large amount of information and it is essential
that a practitioner maintains this in an easily accessible manner.
Within the written notes the established minimum information is
[4]: · Identification data – name, date of birth, phone
numbers and emergency contact information · Medical history – thorough investigation to
include a minimum of :- *
Name and phone number of physician *
Dentists’ own evaluation of patient’s general
health & appearance *
List of systemic disease – diabetes, rheumatic
fever, hepatitis etc. *
Any ongoing medical treatment *
Any bleeding disorders, drug allergies, smoking
& alcohol history *
Any cardiac disorders *
Relevant family medical history *
Pregnancy *
Physical and emotional tolerance for procedures [3] · Dental history · Clinical examination to include an accurate
charting · Diagnosis · Treatment plan · Documentation of Informed consent How to Create and Maintain
A Patient Record Lawney
[3] describes a simple ten step procedure to ensure that your records
are adequate. A modified and expanded version, appropriate to the National
Health Service and UK dentistry, is given below: 1.
Use a consistent style for
entries – the
appearance of the record is enhanced by using the same colour and type
of pen, use the same abbreviations and notations etc. 2.
Date
and explain any corrections – it may be a fatal error in a malpractice case
if records appear doctored in any way.
These unexplained corrections can undermine the credibility of
the entire record and of the treating dentist 3.
Use single-line crossout
– this preserves the integrity of the record and shows that you have
nothing to hide 4. Do
not use correction fluids – not only is this messy, especially on coloured
NHS forms, but it is conspicuous and may indicate that there has been an
attempt to hide information 5.
Use ink – pencil can fade and
opens up the question of whether or not the records have been altered 6.
Write
legibly
– an illegible record may be as bad as no record at all. Difficult to read entries can lead to guesswork by others and
this may not be favorable to you 7.
Express
concerns about patient needs
– by doing this you are documenting that you have listened,
empathized, understood and acted upon the wishes of your patient.
It also enables an explanation to be given should a patients’
wishes be unobtainable or unrealistic and can help instantly diffuse a
malpractice case. Use quotations to indicate patient comments as
distinct from your own. 8.
Never
write derogatory remarks in the record
- Superfluous entries only serve to convey a feeling of
unproffesionalsim and may give doubts to the overall credibility of the
remainder of the record. Negative
views about patients, such as their failure to follow your advice or
attend appointments, should be recorded in a dispassionate and objective
manner 9.
Document
fully
– there is no need to be sparse with notes, a detailed explanation is
always better than one lacking information.
The NHS provides paper for notes free of charge, take advantage
of this. It is important to
note, however, that each entry should pertain directly
to patient care [5] 10.
Only
use accepted abbreviations for treatments
– this is helpful both in a malpractice situation and also when
transferring records to a different dentist for referral, prior approval
or a change in dentist of record 11.
Collate
documents –
insurance details and other materials from third parties should be
separate from those items which pertain directly to patient care [6] 12.
Maintain
a chronological order
- the use of a hole punch and metal retainer clips in the top of the
record may be helpful to keep loose sheets organized. By
following these steps the production of accurate and defensible records
is possible. Radiographs
The production,
storage and documentation of radiographs is highly variable.
In the Swedish study only 40% of the radiographs were
identifiable to the patient [2]. In
the NHS system the most common technique for radiograph storage is in a
small envelope with the patients’ details, type of radiograph and date
listed on the front. The
patient’s’ record can quickly become filled with these envelopes and
establishing a time line can be difficult and confusing, especially when
endodontic films become co-mingled with diagnostic films.
A mounting method can be a more effective solution to radiograph
storage. A mount, such as
that in Figure I, allows the x-rays to be stored, protected, documented
and easily viewed. This
mount will easily fit within the NHS patients’ record sleeve. A
common problem experienced when viewing a patient’s radiographic
history is that of degradation of the films.
This is usually due to processing errors, especially a failure to
properly fix and rinse the films. This
is most frequently found on those films used for endodontic procedures
as the developing is often hurried and commonly self-developing films
are used. As
well as the need for accurate, well-stored and documented radiographs,
the frequency of radiographic examination is also important.
A patient’s record that is lacking up-to-date radiographs may
jeopardize a malpractice case and is against the patient’s best
interest [7]. There are
established guidelines for the frequency of radiographic examination.
These guidelines should be modified for the individual
patient’s requirements based on caries risk and presence or absence of
periodontal disease and other pathologies. Like
all parts of the dental record radiographs should be stored for 11 years
or up to the age of 25, in the case of children, for protection against
the 1987 Consumer Protection Act. The
details of this will be covered in the next section. Retention of Patient
Records
The
NHS Terms of Service state that dental records should be kept for a
period of two years. The
Regulations state that treatment records, radiographs, photographs and
study models should be retained after the completion of any course of
treatment and care under a continuing care or capitation arrangement for
this period. However, a
patient has the right to raise an action for damages based on
accusations of negligence or Breach of Contract. There are strict time
limits applied to such actions [8] : · Within 3 years of the date when cause of action
occurred · Within 3 years of the patient’s date of knowledge
that the treatment may have been negligent · If a claim is based upon a Breach of Contract, the
action must be raised within 5 years in Scotland and 6 years in England
and Wales. It
is therefore possible that a claim for negligence could happen many
years after the event, and that retention of records for the minimum two
years is inadequate. The defense organizations suggest that records be kept
permanently This is often impossible due to space constraints and so the
advice given by defence organisation is as follows: · Treatment Records, X-rays, Study Models and
Correspondence retained for 11 years after the completion of treatment · For children, retention of records until the
patient is 25 years old · Orthodontic Models - retain the original pre and
post-operative models permanently, discard any intermediates after a
period of 5 years. The
storage area of these records should be secure and access strictly
controlled. By following these guidelines the dental records of a patient
will be available for you should a claim ever be made. Long-term
storage of records
For
records which are dormant, and yet need to be retained, computer
technology provides an economical solution. The use of high density,
removable storage media, such as Iomega Zip disks, allows large
quantites of data to be stored easily and economically. Paper records
and radiographs can simply be scanned into a personal computer using a
desktop scanner. This data is then compressed using technologies such as
JPEG, enabling many records to be stored on a single disk. Commonly used
programs such as Adobe Photoshop contain the JPEG compression system.
Should the record ever be needed again then the files can simply be
printed to a high quality laser printer. By using these techniques the
dentist can protect themselves from malpractice claims without using
valuble storage space. The removal of inactive files streamlines the
filing system leading to an improvement in record system efficiency. Access to patient records Patients,
their legal representatives and police officers may gain access to
dental records. The Access
to Health Records Act 1990 provides the following legislation: · Personal inspection – A patient can request to
see their notes and be guided by the dentist through the contents with
explanations of terminology and technical language.
· Photocopies – A dentist can provide a photocopy
of the notes if the patient requests so in writing.
The record photocopy must be provided within 21 days of the
request or within 40 days if no treatment has been carried out in the
past 40 days. Only details
of the record from 1st
November 1991 can be provided under this Act, however, it may be
necessary to provide earlier entries to explain subsequent treatment.
The dentist may charge reasonable photocopy and postal charges. |
When
asked by a patient for access to records, a caring attitude and prompt
delivery may well help prevent any future claim.
If the request for disclosure of notes comes from a solicitor then
this may indicate that the patient intends to take legal action [9].
Not all of the treatment record is relevant to the matter in
question and so always consult your defense organization prior to
releasing any documents in this situation. As
an additional note it must be remembered that the Data Protection Act 1984
allows patients to view any information about themselves held on computer,
following a written request. Forensic uses of patient records Forensic
dentistry is the overlap of the dental and legal professions.
The most common element of forensic dentistry that a general
practitioner is likely to encounter is supply antemortem (before death)
records to aid in human identification.
Forensic dentists are frequently called upon to identify the
remains of individuals who cannot be identified visually.
This encompasses a large number of situations such as burnt,
grossly decomposed or mutilated remains [10].
The identification is normally carried out by the comparison of
antemortem (before death) and postmortem (after death) records. The
identification of deceased individuals is an essential element in the
process of death certification and is a crucial component in the
investigation of homicides or other sudden deaths.
It is vital to have expeditious and accurate identification both
for police officers and relatives [12].
Until identification can be confirmed estates cannot be settled,
death benefits cannot be paid and surviving
spouses are unable to remarry. Perhaps
of most importance is that the identification of the dead is an essential
component of the grieving process and is a necessary part of human dignity
in a civilized society [13]. The
police officers in charge of the case will normally call upon the dentist
to provide details of dental records.
It must be remembered that police officers have no statutory rights
to inspect or remove a patient’s records without their consent.
However, the law allows for special circumstances and it is
reasonable to hand over an individual’s record if it enables them to be
identified or excluded. The
consent of the nearest relative or estate executor may also be sought if
required. The
availability of contemporaneous and clear notes is essential in forensic
dental identification. If
notes are incorrect or dated this can complicate and even negate a
positive identification [15]. It
is in such situations where the errors highlighted by Borrman and others
can cause crucial mistakes to be made [2],[16].
When a request for records is received the entire record is useful,
including such items as lab prescriptions and study models [17].
Many documented cases have used the unique pattern of the palatal
rugae recorded on an orthodontic study model to identify a young
individuals with no dental restorations [18]. The
police may require access to an individual’s record for another criminal
matter. They may, for example, want to see an appointment book to
establish an alibi or time line. In
these circumstances a warrant is required, if the patient has not agreed
to the release, as it can be argued that the release of notes in this
instance is not in the patient’s best interest.
If in doubt always contact your defense organization. Confidentiality Dentists
are in a privileged position to learn much about patients and this
knowledge is acquired under the assumption that it is confidential.
Confidentiality encourages open and honest communication, enhancing
the dentist-patient relationship, and encourages respect for patient
autonomy and privacy [19]. Confidentiality
is taken very seriously by professional bodies and an alleged breach of
this trust would be investigated by the Professional Conduct Committee of
the General Dental Council. There
are circumstances in which information can be disclosed [20], and they
include: · Sharing of relevant information with other health
care professionals involved in a patients’ treatment · Information may be passed to a third part if the
patient or legal adviser gives written consent, e.g.
an insurance company · Where information is requested about a deceased
patient and consent of the estate or relative is sought and the
investigation of sudden, suspicious or unexplained deaths · Information required in the preparation of legal
reports containing only relevant dental treatments · Investigation of sudden, suspicious or unexplained
deaths · Access to dental records by the police.
Search and seizure warrants may not include dental records, and
therefore should be carefully checked · Clinical research protocols and peer review
procedures. The name of the
patient must be kept confidential. If
information is to be used for teaching purposes then the patients’
consent must be obtained. The
area of confidentiality of childrens’ dental information can be
confusing. Those individuals of 16 years and older should be considered
adults, however for those 16 and under the dentist still has a duty of
care and therefore confidentiality to the child.
This duty is combined with a duty to the parents, especially in the
area of consent to treatment. Children
who are victims of abuse require special management and the dentist may
have an overriding responsibility to break confidentiality and report
their findings to the appropriate authorities. Special
guidelines exist for AIDS/HIV and sexually transmitted diseases.
Strict confidentiality must be maintained when dealing with these
individuals. Disclosure of such information could lead to a complaint of
serious professional misconduct. Conclusions The
production, retention and release of clear and accurate patient records is
an essential part of the dentist’s professional responsibility.
Success in this task will assist the dentist should a medicolegal
claim be made and can assist the police and coroners in the correct
identification of individuals. References 1.
Platt
M, Yewe-Dyer M. How
Accurate is your Charting ? Dental
Update 1995; 22(9):374 2.
Borrman H, Dahlbom U, Loyola E,
Rene N. Quality
evaluation of 10 years patient records in forensic odontology.
Int J Legal Med 1995; 108:100-4 3.
Lawney
M. For the Record. Understanding
Patient Recordkeeping. N Y State Dent J
1998; 64(5):34-43. 4.
Collins
D. What A Dentist Should Know About the Oral Health Record.
Northwest Dentistry 1996; 75(1):35-9.
5.
Ray
AE, Staffa J. The
Importance of Maintaining Adequate Dental Records.
N Y State Dent J 1993; 59(9):55-60.
6.
Nelson
GV. Guidelines to the prevention of problems in recordkeeping.
Part 1.
Pediatr Dent 1989; 11(2):174-7. 7.
Plunkett
LR. Managing Patient Records.
N
Y State Dent J 1997; 63(4):10-4.
8.
Medical
& Dental Defense Union of Scotland.
Patient records. Retention
& Disclosure 9.
Friedland B, Haggerty JM,
Responding to Attorney Requests for Patient Information.
J Mass Dent Soc 1997; 46(3):14-16.
10.
American Board of Forensic Odontology.
Body Identification Guidelines.
JADA 1994; 125:1244-54. 11.
Whittaker DK, MacDonald D. A
Colour Atlas of Forensic Dentistry.
1st ed. 1989, London. Wolfe
Medical, p. 133. 12.
Camerson JM, Sims BG Forensic Dentistry. London:
Churchill Livingstone, 1974 13.
Rothwell R, Haglund W, Morton TH Jr.
Dental identification in serial homicides: the Green River Murders.
JADA 1989; 119:373-9. 14.
Silverstein HA, Comparison of Antemortem and Postmortem Findings, in
Manual of Forensic Odontology, Bell G, Bowers CM, Editors.
1995, American Society of Forensic Odontology: Vermont.
p. 31-35. 15.
Carlson
HW, Grauerholz J, Yacovone J, The Value of Patient Records In
Forensic Odontology. Rhode Island Dent J 1978; 11(3):6-10. 16.
Hill
IR, Inconsistency in dental evidence.
Med Sci Law 1988; 28:212-6.
17.
Whittington BR, The importance of adequate ante-mortem dental
records for post-mortem identification: a case report.
N Z Dent J 1991; 87:17-9.
18.
Reder
SA, Dental Identification, in Manual
of Forensic Odontology. Bell
G, Bowers CM, Editors. 1995,
American Society of Forensic Odontology: Vermont.
p. 62-5. 19.
Skifkas
PM, Guarding the files. Your
role in maintaining the confidentiality of patient records.
JADA 1996; 127:1248-1252. 20.
Medical
& Dental Defense Union of Scotland.
Confidentiality
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