Dental Nurses: How to write patient notes


iStock_000001396022XSmallPatients’ notes are a legal document. Dental nurses therefore have a responsibility to make these records as accurate and detailed as possible so that all relevant information is present and correct.

This includes accurately charting all present teeth and past treatment, all treatment needed, correctly labelling and mounting radiographs, maintaining an updated medical history, keeping a record of all correspondence with specialists etc, retaining consent forms and recording accurate clinical notes every time the patient attends.

It is important to maintain correct records firstly so that all information about the patient is available in order to provide them with the treatment and care most suitable for them, and secondly for legal reasons.  If there is any dispute between the patient and dentist it is important that the dentist can provide accurate notes showing any diagnosis, advice or treatment they have given to the patient, and their reasons for doing so.  The dentist therefore can provide written evidence justifying any treatment or advice they have given to the patient.
Patient Details
A record should be kept of the patient’s date of birth, current address and telephone number and/or email address. The patient should be routinely asked if there is any change in contact details.
 
Attendance
Records should be kept of all appointments patients have failed to attend, have cancelled or attended late.
 
Medical History
Patients’ medical history should be updated every time the patient attends. This is extremely important as certain drugs the patient may be taking, such as anticoagulants, can cause excessive bleeding after extractions, and other medication can react with drugs administered during dental treatment, such as the adrenaline contained in some local anaesthetic solutions.
 
If medical history is checked verbally a record should be made in the patient’s notes. Ideally the patient should be given a medical history form to complete prior to the appointment which can then be scanned to the patient’s notes if these are computerised, or kept with the patient’s record card.
 
The following should be recorded:
The patient’s GP
any medical conditions such as epilepsy or diabetes
any allergies such as Asthma or Penicillin allergy
any infectious diseases such as Hepatitis B or HIV
if the patient is pregnant
any medication  the patient is currently taking
if the patient is currently undergoing any treatment or has had any recent operations
oral cancer risk factors including whether the patient smokes and average weekly alcohol consumption
 
Charting
Dental charting is a diagrammatic representation of teeth and their surfaces providing a visual note of the patient’s teeth and any treatment they have had on them. Charting is not only important in the respect that it shows the dentist an immediate representation of the patient’s mouth so is an important aid in patient diagnosis and treatment, but it is also an aid in forensic identification of bodies. Correct charting can be the only means of identifying bodies in cases such as burn victims, so it is of vital importance that it is recorded accurately.
 
At the patient’s first visit a full base chart should be recorded showing all teeth present and any treatment that has been carried out on them. The charting should be checked each time the patient attends and updated if there are any changes.
 
There are two main systems of tooth notation available when referring to specific teeth in the clinical notes. In the United Kingdom Palmer tooth notation is often used. In handwritten notes it involves using a quadrant symbol and the tooth number:
__                                        __
|           lower left                     |      lower right      __|  upper right        |__        upper left
 
 
As demonstrated this does not work well on computerised notes (!) so quadrants are referred to as UL - upper left, UR - upper right, LL - lower left and LR - lower right.
 
The International Dental Federation two-digit system is a globally recognised form of tooth notation where quadrants are recognised as numbers:  1 - upper left, 2 - upper right, 3 - lower left, 4 - lower right, and for deciduous teeth, 5 - upper left,  6 -  upper right, 7 - lower left and 8-  lower right.
 
Both forms of notation are acceptable and the dental nurse should use the system that the dentist prefers.
 
Other forms of charting may be required such as charting the findings of a Basic Periodontal Exam - this ideally should be carried out at every examination appointment. Pocket, mobility, plaque or surface wear charting may also be required.
 
Clinical Notes
At an examination or emergency assessment appointment the first thing that should be recorded in the clinical notes is the patient’s chief complaint, followed by anything else the patient complains of or wishes to report. This should be recorded as closely as possible to the patient’s own description of their symptoms.
 
Any diagnosis or observations the dentist makes should then be recorded along with any charting updates. All discussions regarding treatment options, including costs or any questionable prognosis of any treatment, changes in treatment plans or post-operative warnings should be recorded.
 
At appointments where patients are undergoing treatment concise details should be made of the treatment being carried out and correct notation of where it is being carried out, along with records of any drugs administered and materials/equipment used. Records should be made of any post-operative advice given.
 
Notes should always be recorded during and directly after the patient’s visit as it is required that they are contemporaneous. It must also be taken into consideration that patients’ can request to see their clinical notes; therefore they must be written in a professional manner with no derogatory comments made about the patient. For example, if a patient attended complaining of a broken tooth a note should be made of this, including how and when it was broken, what tooth or area of mouth patient describes and any symptoms:
‘Pt c/o broken tooth UR area this morning whilst eating cereal, causing sensitivity to cold.’
The dentist’s diagnosis, any vitality tests or radiographs, and any discussions about treatment plans should then be recorded:
‘O/e: UR5 fractured mesio-buccal cusp, pt has a heavy bite and not much tooth left so advised patient that a crown is the best option. Explained to patient tooth can have a composite restoration but that it may not last long. Explained differences between gold and porcelain bonded crown, advised patient that PBC was the most aesthetic option, but gold is slightly stronger and helps periodontal condition. Patient concerned about crown blending in with existing crowns and veneers, concerned about metal becoming visible due to gingival recession as this has happened to the patient before. Discussed option of Lava crown (metal free), shown patient some photographs of Lava crowns, patient wishes to go ahead. PA taken of UR5 to check suitability of tooth for crowning, PA shows tooth to be suitable .Pt given verabl and written estimates and consent form to sign.’
Although the dental nurse should record as much information as possible in the patient’s clinical notes and write them as accurately as possible, the dentist is ultimately responsible for their content, so before any notes are saved and the patient’s appointment is marked as complete, the dentist should check that the notes are satisfactory and make any necessary additions or ammendments.
Radiographs
If radiographs are processed and mounted digitally then they should be attached to the correct patient’s notes, orientated correctly and labelled accurately recording the type of radiograph and teeth present on radiograph. Reasons for taking radiograph and findings should be recorded in the patient’s clinical notes. Radiographs that are manually processed should also be correctly mounted and labelled and kept with the patient’s record card.
 
Correspondence
Any correspondence with specialists or hospitals such as letters or emails should be retained and either scanned to the patient’s digital notes or kept with the patient’s record card. Any paper work regarding confidential information about patients should be shredded after scanning to patient’s notes. This also applies to medical history forms.
 
A record of any correspondence made regarding the patient, or with the patient, over the telephone should be made in the patient’s clinical notes.
 
 
 

Patients’ notes are a legal document. Dental nurses therefore have a responsibility to make these records as accurate and detailed as possible so that all relevant information is present and correct. This includes accurately charting all present teeth and past treatment, all treatment needed, correctly labelling and mounting radiographs, maintaining an updated medical history, keeping a record of all correspondence with specialists etc, retaining consent forms and recording accurate clinical notes every time the patient attends.

It is important to maintain correct records firstly so that all information about the patient is available in order to provide them with the treatment and care most suitable for them, and secondly for legal reasons.  If there is any dispute between the patient and dentist it is important that the dentist can provide accurate notes showing any diagnosis, advice or treatment they have given to the patient, and their reasons for doing so.  The dentist therefore can provide written evidence justifying any treatment or advice they have given to the patient.

 

Patient Details

A record should be kept of the patient’s date of birth, current address and telephone number and/or email address. The patient should be routinely asked if there is any change in contact details.
 

Attendance

Records should be kept of all appointments patients have failed to attend, have cancelled or attended late.
 

Medical History

Patients’ medical history should be updated every time the patient attends. This is extremely important as certain drugs the patient may be taking, such as anticoagulants, can cause excessive bleeding after extractions, and other medication can react with drugs administered during dental treatment, such as the adrenaline contained in some local anaesthetic solutions.
 
If medical history is checked verbally a record should be made in the patient’s notes. Ideally the patient should be given a medical history form to complete prior to the appointment which can then be scanned to the patient’s notes if these are computerised, or kept with the patient’s record card.
 

The following should be recorded:

The patient’s GP

any medical conditions such as epilepsy or diabetes

any allergies such as Asthma or Penicillin allergy

any infectious diseases such as Hepatitis B or HIV

if the patient is pregnant

any medication  the patient is currently taking

if the patient is currently undergoing any treatment or has had any recent operations

oral cancer risk factors including whether the patient smokes and average weekly alcohol consumption

 

Charting

Dental charting is a diagrammatic representation of teeth and their surfaces providing a visual note of the patient’s teeth and any treatment they have had on them. Charting is not only important in the respect that it shows the dentist an immediate representation of the patient’s mouth so is an important aid in patient diagnosis and treatment, but it is also an aid in forensic identification of bodies. Correct charting can be the only means of identifying bodies in cases such as burn victims, so it is of vital importance that it is recorded accurately.
 
At the patient’s first visit a full base chart should be recorded showing all teeth present and any treatment that has been carried out on them. The charting should be checked each time the patient attends and updated if there are any changes.
 

There are two main systems of tooth notation available when referring to specific teeth in the clinical notes. In the United Kingdom Palmer tooth notation is often used. In handwritten notes it involves using a quadrant symbol and the tooth number:

__                                        __
|           lower left                     |      lower right      __|  upper right        |__        upper left
 
 
As demonstrated this does not work well on computerised notes (!) so quadrants are referred to as UL - upper left, UR - upper right, LL - lower left and LR - lower right.
 
The International Dental Federation two-digit system is a globally recognised form of tooth notation where quadrants are recognised as numbers:  1 - upper left, 2 - upper right, 3 - lower left, 4 - lower right, and for deciduous teeth, 5 - upper left,  6 -  upper right, 7 - lower left and 8-  lower right.
 
Both forms of notation are acceptable and the dental nurse should use the system that the dentist prefers.
 
Other forms of charting may be required such as charting the findings of a Basic Periodontal Exam - this ideally should be carried out at every examination appointment. Pocket, mobility, plaque or surface wear charting may also be required.
 

Clinical Notes

At an examination or emergency assessment appointment the first thing that should be recorded in the clinical notes is the patient’s chief complaint, followed by anything else the patient complains of or wishes to report. This should be recorded as closely as possible to the patient’s own description of their symptoms.

Any diagnosis or observations the dentist makes should then be recorded along with any charting updates. All discussions regarding treatment options, including costs or any questionable prognosis of any treatment, changes in treatment plans or post-operative warnings should be recorded.

 

At appointments where patients are undergoing treatment concise details should be made of the treatment being carried out and correct notation of where it is being carried out, along with records of any drugs administered and materials/equipment used. Records should be made of any post-operative advice given.

 

Notes should always be recorded during and directly after the patient’s visit as it is required that they are contemporaneous. It must also be taken into consideration that patients’ can request to see their clinical notes; therefore they must be written in a professional manner with no derogatory comments made about the patient. For example, if a patient attended complaining of a broken tooth a note should be made of this, including how and when it was broken, what tooth or area of mouth patient describes and any symptoms:

‘Pt c/o broken tooth UR area this morning whilst eating cereal, causing sensitivity to cold.’

The dentist’s diagnosis, any vitality tests or radiographs, and any discussions about treatment plans should then be recorded:

‘O/e: UR5 fractured mesio-buccal cusp, pt has a heavy bite and not much tooth left so advised patient that a crown is the best option. Explained to patient tooth can have a composite restoration but that it may not last long. Explained differences between gold and porcelain bonded crown, advised patient that PBC was the most aesthetic option, but gold is slightly stronger and helps periodontal condition. Patient concerned about crown blending in with existing crowns and veneers, concerned about metal becoming visible due to gingival recession as this has happened to the patient before. Discussed option of Lava crown (metal free), shown patient some photographs of Lava crowns, patient wishes to go ahead. PA taken of UR5 to check suitability of tooth for crowning, PA shows tooth to be suitable .Pt given verabl and written estimates and consent form to sign.’

Although the dental nurse should record as much information as possible in the patient’s clinical notes and write them as accurately as possible, the dentist is ultimately responsible for their content, so before any notes are saved and the patient’s appointment is marked as complete, the dentist should check that the notes are satisfactory and make any necessary additions or ammendments.

Radiographs

If radiographs are processed and mounted digitally then they should be attached to the correct patient’s notes, orientated correctly and labelled accurately recording the type of radiograph and teeth present on radiograph. Reasons for taking radiograph and findings should be recorded in the patient’s clinical notes. Radiographs that are manually processed should also be correctly mounted and labelled and kept with the patient’s record card.
 

Correspondence

Any correspondence with specialists or hospitals such as letters or emails should be retained and either scanned to the patient’s digital notes or kept with the patient’s record card. Any paper work regarding confidential information about patients should be shredded after scanning to patient’s notes. This also applies to medical history forms.
 
A record of any correspondence made regarding the patient, or with the patient, over the telephone should be made in the patient’s clinical notes.
 
 
 
Kim RDN
 

 

 

 

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