New standard on record-keeping

The importance of good record-keeping has been emphasised repeatedly for dental practitioners, often as a formidable resource in the unfortunate case of disciplinary proceedings. Dr Kiran Keshwara, dentolegal consultant at Dental Protection, highlights the important changes that have taken place when it comes to record-keeping, and considers how to address and incorporate them

On 1 October 2020, the Dental Board of Australia (the Board) retired the four-page Guidelines on dental records, as it had formed the view that the Code of conduct contained adequate guidance for dental practitioners on record–keeping, eliminating the need for a standalone document.  

In addition to the guidance in the Code of conduct, the Board has developed a fact sheet and a self-reflective tool to help clinicians understand and comply with their obligations.

Fact sheet

Setting out the expectations of clinicians, the fact sheet directs them to the relevant documentation.  

A practitioner is expected to:  

• Practice in accordance with the Board’s regulatory standards codes and guidelines, including:  

• The Code of conduct, which contains information on confidentiality, privacy and informed consent  
• Ongoing CPD courses on record–keeping  

• Ensuring appropriate professional indemnity insurance is in place

Comply with:  

• The relevant state and territory legislative requirements on health records  
• Relevant privacy requirement – this includes the Privacy Act 1988, which details the use, disclosure and release of a patient’s personal information and details  

Understand:

• What constitutes a health record
• Your responsibilities when making a health record  
• What should be recorded in the health record

Code of conduct

This is the main document containing the standards that all practitioners are held to and was developed in 2014.  

Along with Section 2 (Providing good care) and Section 3 (Working with patients or clients), Section 8.4 of the Code of conduct specifically details expectations of clinicians concerning dental records.  

It states that good practice involves:

1. Keeping accurate, up-to-date, factual, objective and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients or clients, medication and other management in a form that can be understood by other health practitioners
2. Ensuring that records are held securely and are not subject to unauthorised access, regardless of whether they are held electronically and/or in hard copy
3. Ensuring that records show respect for patients or clients and do not include demeaning or derogatory remarks
4. Ensuring that records are sufficient to facilitate continuity of care
5. Making records at the time of events or as soon as possible afterwards
6. Recognising the right of patients or clients to access information contained in their health records and facilitating that access, and
7. Promptly facilitating the transfer of health information when requested by patients or clients.

Self-reflective tool

This is the newest document made available to practitioners and it should be reviewed by all dental practitioners. It is a series of questions and statements that encourages clinicians to think about the different aspects of the records created, which will further help clinicians identify any gaps in their knowledge, skills and systems.  

This information can then be used this to improve the record–keeping process, encourage discussion amongst clinicians and highlight areas where further record–keeping CPD is required.  

It is important to remember that the self-reflective tool is not a comprehensive list of the detail that should be included in patient records. It should be used as a starting point for reflection, considering the records and understanding the type of information that should be included.  

The self-reflection tool encourages clinicians to complete random audits of the records created to check, and remind them of, important aspects of the dental records including:

• Ensuring that records are accurate and up to date  
• Evidence that patients were fully informed of their options and these options were explored in detail, including costs and personal circumstances
• Diagnostic data (e.g. dental charting, temporomandibular joint examination findings, pulp sensibility tests, and periodontal probing)
• Diagnoses
• Medication prescribed, including information on dose, quantity and instructions provided
• Continuity of care

Want to know more? Dental Protection Members can access a recording of the webinar, ‘What does the new standard on record–keeping mean for me?’ presented by Dr Kiran Keshwara and Dr Annalene Weston, here.

You can also access the RiskBites podcast ‘How to document risks and warnings’ through your preferred podcast platform, or via the Dental Protection webpage.  

This article first appeared in the December 2020/January 2021 edition of the Western Articulator magazine.

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