The day-to-day running of a practice can be hectic at times, so many dental professionals use set systems and procedures to streamline their work. After all, less time on the backend means more time on patient care. But occasionally, cutting corners can lead to unwanted risk. This is especially true when it comes to patient records. Taking shortcuts on charting, such as using preestablished templates, may seem like a convenient time saver, but it can cause more headaches down the road. At best, it can leave patients unhappy. At worst, it can lead to potential liability claims.
In one case reported to The Dentists Insurance Company’s Risk Management Advice Line, a patient came in for a routine cleaning. She called the office the next day to say she felt cheated because she did not receive a polish at the end of the cleaning. The office staff assured her that the polish is part of the cleaning and they would look into the matter. They reviewed the notes and found documentation that polishing did, in fact, take place. As a goodwill gesture, the dentist allowed the patient to return to the office for another polish. The patient was pleased.
Three weeks later, another patient called and reported there was no polish at the end of the cleaning. Again, the chart note indicated the polish took place. This time, the dentist looked into the matter more critically and found that the polish was part of the treatment template and was automatically populated. He discovered that at times, the hygienist did not do the polish due to time constraints.
While digital templates can keep notations clear and consistent, they should be used with caution, said Senior TDIC Risk Management Analyst Taiba Solaiman. The use of templates, especially if fields are auto-populated, can lead to errors and omissions.
“Inconsistent notes can reduce the credibility of the dentist, and the onus is on the dentist to make sure that chart notes are an accurate depiction of what transpired at each appointment,” Solaiman said. “It’s best to refrain from pre-populating notations whenever possible.”
Although no great harm came from the case above, the use of templates can have more serious effects. In another case reported to TDIC, a 4-year-old patient presented for restorative treatment due to rampant decay on multiple teeth. The procedure was performed under conscious sedation. Vital signs were obtained and noted on the patient’s sedation record. At the end of the procedure, the patient was breathing and her eyes were open, but the dentist could not arouse her. She was immediately placed on oxygen. The patient wasn’t responding to verbal or physical stimuli. Her blood pressure and oxygen saturation levels were dropping, so office staff called 911. The paramedics arrived and transported the patient to a local hospital.
Upon reviewing the patient’s chart entries the following day, the dentist noticed that there was no mention of the patient’s drop in blood pressure or oxygen saturation levels. Even more concerning was a note that the patient was discharged “awake, alert and ambulatory.” The dentist then contacted TDIC Risk Management for advice.
One of the concerns in the above case is that some of the recordings of vital signs on the sedation record were pre-charted in the interest of time. The dentist quickly recognized that this method carries with it the potential for inaccuracies. The dentist was concerned that the parents would view the time-saving approach as reflective of an overall approach to patient care, which may lead them to wonder what other “shortcuts” could have led to this incident. While no liability has been established in this case, it brings to question the safety and accuracy of the record-keeping method used. The analyst advised the dentist against pre-charting and cautioned the dentist about editing entries after the fact.
“We do not recommend using pre-charted notes, as the notes may not accurately describe the specific details of the treatment completed or any unusual occurrences,” Solaiman said. “When dentists or staff use predeveloped templates, sometimes the information may not be complete or it may not be applicable to the actual treatment rendered.”
Whether digital or written, comprehensive and accurate patient records are the best defense in liability claims. They should include (among other information) diagnoses, treatment plans, progress notes, vital and diagnostic signs, exam and treatment notes, informed consent discussions and forms and all interactions with patients, such as conversations, phone calls and emails.
“Records serve as credible evidence of discussions between you and your patient as well as the actual treatment provided,” Solaiman said. “Accurate and complete records are critical for demonstrating sound clinical judgement.”
Dentists and their staff should be extremely careful in not only what they document, but how they document. Chart notes should be written during, or soon after, the appointment. The more time that passes, the greater the likelihood of details being forgotten or inaccurate. Although entries can be edited, after-the-fact edits increase scrutiny and can appear suspicious in a liability case. Practice owners should also review all chart notes completed by their staff. Legally, the dentist is responsible for all errors that occur within his or her practice.
“We also recommend that the dentist check over every provider note to make sure that the entry is correct and that the dentist feels confident speaking to the notes,” Solaiman said.
Faulty records can strengthen a professional liability case against a dentist in litigation. Many plaintiff attorneys are becoming increasingly sophisticated in reviewing treatment charts. Audits can be run on electronic records that show the history of all entries made by whom and when. Records come under intense scrutiny, and the slightest mistake or omission can make an otherwise defensible case indefensible.
Accurate, thorough and up-to-date treatment records are a dentist’s best defense in a liability claim. They are considered legal documents and, as such, must be created and maintained with the utmost care. Preestablished treatment templates may save time, but what’s saved in minutes can, and often will, create more problems down the road. These measures can also appear careless and insensitive to patients, eroding confidence and leading them to believe that the practice values production more than patient care. Ultimately, patient safety should supersede convenience.
TDIC’s Risk Management Advice Line is a benefit of CDA membership. Schedule a confidential consultation with an experienced risk management analyst or call 800.733.0633.
Reprinted with permission from the September issue of the CDA Journal.
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