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:
Comply with:
Understand:
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:
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:
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.
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