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.
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.
The following should be recorded:
• The patient’s GP
• any medical conditions such as epilepsy or diabetes
• any infectious diseases such as Hepatitis B or HIV
• any medication the patient is currently taking
• oral cancer risk factors including whether the patient smokes and average weekly alcohol consumption
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:
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.