Dental Records, Documentation, Consent and ReferralDr. Omar AlkaradshehBDS, MFD RCSI, FFD RCSI, D.Ch.Dent, EFP.

Outline

• Dental records

• Documentation

• Consent

• Referral

Dental Records

Why make and retain records• The patient record provides all privileged parties with:1. History & details of patient assessment 2. communications between dentist and patient3. specific treatment recommendations, alternatives, risks, and

care provided. 4. Cost5. Consent6. assisting with complaint resolution, medico-legal and

professional standards reviews

7. documenting compliance with insurer, other third party payer and government subsidized

8. forensic purposes.

Documentation & Dental Records

• Professional, ethical and legal responsibilities dictate that a complete chart and record documenting all aspects of each patient’s dental care be maintained.

• Patient records must be well-organized, legible, readily accessible, and understandable.

• If the practitioner of record were, for any reason to become unable to practise, another dentist should be able to easily review the chart and carry on with the care of the patient.

What constitutes records?

• Accurate patient details• Completed written medical histories• Notes made by clinicians and staff.• Consent documents• Copies of correspondence about and with the patient.• Radiograph ,charts, tracings, measurements• Diagnostic images, reports and casts• Special tests• Examination findings• Photographs• Records of financial transactions

Contents of Dental Records• A) Patient details• B) Substitute decision maker• C) Consents and restrictions on disclosure• D)Practitioner details• E) Clinical details

Patient details:

identifying details of the patient (including full name, sex, date of birth and address, including email and telephone number);

and the current medical history of the patient, including any adverse drug reactions

Substitute decision maker

• The dental record should contain the name, address and contact details of the parent, guardian or substitute decision maker and the relationship of the substitute decision maker to the patient.

Consents and restrictions on disclosureThe dental record should include a record of consents

provided by the Patient. • if written consent is provided, the signed consent form;• if written consent is not provided, then a description of the

treatment as explained to the patient.Advice given to patient on:• treatment options;• the relevant material risks and benefits of those options;• pre- and post-treatment instructions;• likely outcomes;

Consent & restrictions to disclosure• relevant questions, comments or concerns expressed by

patients over offered treatments;

• any treatment advice that the patient was unwilling to accept;

• any comments or complaints by patients about treatment provided;

• if there are any restrictions on disclosures, including in relation to any directions from the patient or family law restrictions;

• if the patient has made a direction in relation to care, such as a restriction on blood transfusions, etc.

Clinical details

For each appointment:(1)clear documentation describing: • the date of visit;• the identifying details of the practitioner providing the treatment;• information about the type of examination conducted;• the presenting complaint; relevant history; clinical findings and

observations;• diagnosis;• treatment plans and alternatives;• all procedures conducted;• a medicine/drug prescribed, administered or supplied or any

other therapeutic agent used (name, quantity, dose, instructions);• details of advice provided;

(2) unusual sequaelae of treatment, significant events or adverse events;

(3) radiographs and other relevant diagnostic data; digital radiographs must be readily transferable

(4)instructions to and communications with laboratories.

(5) Referral letters and quotation fees

(6)Records should also indicate when the patient failed to attend and provide for adequate follow up.

Documentation & Dental Records

• The extent of the detail required for each individual dental record will vary from patient to patient.

• It will also depend on the conditions with which the patient presents, and the complexity of the treatment that is required.

• However, certain baseline data should be common to all dental patients.

Records should be:• Accurate & concise information• Made in a chronological order• legible with standard abbreviations.• Dentists are allowed only to collect clinically relevant

information• completed as soon as practicable after the service has been

rendered by the dentist.• Dental records must be understandable by third parties,

particularly other health care providers.

Records should be:• Retrievable when required.• All comments must be provided based upon the facts, do not

include emotional language or make defamatory statements.• A treating dental practitioner must not delegate responsibility

for the accuracy of medical and dental information to another person.

• The treating dentist should ensure that only authorised and suitably qualified persons provide clinical information from the dental record to patients and other persons

• Dentists should protect the privacy and confidentiality of dental records and comply with all relevant Privacy Laws.

How to document?• Charts• Consents• Notes• Photographs• Radiographs• video

Progress notesAn entry must be made in the patient’s record that accurately

and objectively summarizes each visit. The entry must minimally contain the following information:Date of visitReason for visit/chief complaintRadiographic exposures and interpretation, if anyTreatment rendered including, but not limited to, the type and

dosage of anesthetic agents, medications, and/or nitrous oxide/oxygen and type/duration of protective stabilization.

Post-operative instructions and prescriptions as needed

Progress notes

In addition, the entry generally should document: Changes in the medical history, if any Adult accompanying child verification of compliance with

preoperative instructionsReference to supplemental documents Patient behaviour guidanceAnticipated follow-up visit

A standardized format may provide the practitioner a way to record the essential aspects of care on a consistent basis

Progress Note

Progress Notes

Progress Notes

Correctionsanddeletions

• striking out the incorrect words and rewriting the correct words.

• If the document is being rewritten the original document should be kept as a reference.

• liquid paper products or erasable pens should not be used.• Any amendments to dental records after they have been

initially generated should be clearly recorded and dated. • Corrections to clinical information should not remove the

original information.

Features which make health information specialConfidentiality of collection:

Health information is collected in a situation of confidence and trust in the context of a dentist/patient relationship and may be of a sensitive nature.Sensitivity of information:

details about an individual’s body, lifestyle and practices which are

particularly intimate or which may, if improperly disclosed, be misused.

Duration of retention :

Health information may be required long after it has ceased to be needed for the original episode of care and treatment.

Use and disclosure

• Dental records should be used and disclosed for their primary purpose of collection (ie to treat the patient) or for secondary or purposes permitted under Privacy Laws (for example, for billing purposes or if you are provided with a court order such as a search warrant or subpoena).

• Detail records containing identifying personal information should not be used for research purposes without the consent of the patient or unless a statutory exemption in relation to patient consent applies.

Storageand security of records

Storageand security of records• Dental practices must take reasonable steps to protect the personal

information it holds from Misuse and loss and from unauthorised access, modification or disclosure.

• All file cabinets should be locked and kept in a room which is not accessible to the general public.

• All computers should be password protected. • Dentists should ensure records are maintained on durable paper,

some forms of medical photographic imaging fades with time and should be copied.

• Dental records can be sent by secure fax or email. When sending dental records by post, traceable methods should be used such as registered mail or express post.

• If a health record is destroyed after the required retention periods, it must be destroyed in a secure manner, such as document shredding.

Retention of Records• If health information from an adult – for at least seven years from the last occasion on which a

health service was provided to the individual by the health service provider;• If individual was under the age of 18 years – at least until the individual has attend the age of 25

years.• If you delete or dispose of health information, you must keep a record of the name of the

individual to whom the health information related, the period covered by it and the date on which was deleted or disposed of.

• A health service provider who transfer health information to another organisation and does not continue to hold a record of that information must keep a record of the name and address of the organisation to whom or to which it was transferred.

• Unless required by law, or an agreed transfer of records to another treating practitioner, copies and not originals of records should be released. If original records are released, dental practitioners should obtain an acknowledgment receipt and also retain copies for their own records.

• Diagnostic images and reports should be kept as part of the dental record. It is a reasonable alternative that diagnostic images and diagnostic casts be given to the patient for retention.

• Subject to mandatory retention requirements, dentists must take reasonable steps to destroy or permanently destroy or permanently de-identify personal information if it is no longer needed for any purpose for which the information may be used or disclosed under Privacy Laws.

Legal implications• The dental chart is a legal document. • first line of defence in a malpractice suit • Record alterations• Why??

• A poorly written, inadequate narrative can be the most damaging evidence against a clinician in malpractice cases

Documentation and record keepingin JUH• -2 floor, JUH• Undergrad, postgrad students & specialty clinics• ~4000 seen in the first term in 2013/2014 year in student

clinics only.• Accurate record keeping is essential to ensure continuity of

patient care and meeting legal requirements• Records retention policy for 10 years.

Electronic records

The principles applying to written records also apply to electronic records. Electronic records must provide prompt access to information, be capable of

generating appropriate clinical reports, be regularly backed up and supported by an appropriate disaster recovery plan.

Electronic records should be time logged and, if codes are used, they should be readily convertible to conventional language.

a dental practitioner’s records must show who made each entry and when it was made;

it must not be possible for entries to be changed without trace, that is, there must be an audit trail;

there should be security procedures such as Password - only access there must be a standard procedure for entering treatment record data that is

recorded in an office manual or memorandum to the practitioner’s staff and there must be adequate computer back up and disaster recovery systems in place.

Cessation or Sale of Practice 

When a dental practice closes, dentists must:

• (a)take reasonable steps to notify patients in advance and facilitate the transfer of care for current patients to other practitioners (including the transfer or provision of dental records of those patients);

• make appropriate arrangements for the retention and storage of other patient records, including where possible provision to the patient or transfer to another dental practice.

CONSENT

In order to practise in a professionally responsible manner, a dental practitioner must assist patients to make well-informed decisions about treatment procedures.

Consent may be of three types; impliedVerbalwritten.

Types of Consent• When a patient sits in the dental chair, it can be assumed that

“implied consent” to a non-invasive examination only has been given.

• Any invasive technique that might include periodontal probing, radiographs, blood tests and diagnostic cavities would require further consent from the patient and it is dangerous to rely upon the assumption of “implied consent” to these further procedures.

• Consent would normally be obtained “verbally” after explaining the need for the investigation and any possible sequelae.

• Verbal consent is acceptable for simple general dental care and should be documented in the records.

Written Consent

• Written consent should be obtained for more complex treatment or involves significant risks or adverse effects.

• Written consent must be obtained from all patients having an operation.

• In addition all minors and cases of adult guardianship require written consent

• Achieved by asking the patient to sign a copy of the print out of the treatment plan.

• A signature on a consent form does not itself prove the consent is valid: A signed consent form is not a legal waiver

• For consent to be valid, patients must receive sufficient information about their condition and proposed treatment “Informed Consent”

For consent to be obtained the patient must have:

• 1. Capacity to consent

• People may be considered not to have the capacity if they are: o Minors (<16 years) o Mentally ill o Intellectually impaired o Affected by drugs or alcohol rendering them incapacitated.

• In the case of minors or other persons with a legal disability

the consent of the parent, guardian, or adult guardian should be obtained.

For consent to be obtained the patient must:

• 2. Understand the implications of treatment including: • material risk • time, extent and frequency • outcome • possible complications • cost

• 3. Understand alternative treatment options, including undertaking no treatment

• 4. Have given the consent freely, not under duress

Informed ConsentWhen obtaining consent, patients should be informed of:

• details of diagnosis and prognosis with and without treatment• uncertainties about the diagnosis• options available for treatment• the purpose of all aspects of a proposed investigation or treatment• the likely benefits and probability of success• any possible adverse effects, the risks of the procedure proposed• the likelihood of one or more of the risks coming to pass• likely outcomes if a procedure is not carried out• the need for drains, catheters, tracheostomy, etc.• a reminder that patients can change their mind at any stage• a reminder that patients have the right to a second opinion.

Informed ConsentOther issues that should be discussed at this stage include:• time of appointment or admission• starving instructions• management of usual medication• specific pre-operative preparation that may be required• transport to where the procedure will be performed• specific anaesthetic issues• anticipated duration of procedure• likely recovery period• likely discharge date• specific post-operative care• follow-up requirements• anticipated date of return to full activity

When to obtain a consent?First appointment • in order to understand they may be treated by students under

supervision.

• Identified information or teeth extracted as part of their care may be used for educational and research purposes.

• It should be noted that this is a general consent. Further information may need to be provided and written consent should be sort under ethics guidelines for research projects.

When to obtain a consent?Post-assessment

• Once the investigations are complete, the patient is entitled to advice on diagnosis and treatment planning

• Patients cannot properly consider treatment options if they are not given information on sequelae and prognosis.

“What does the patient need to know?

• the degree of probability of a risk arising, • the seriousness of possible injury

• No treatment should ever be undertaken without giving the patient the opportunity to ask questions and/or raise any concerns or fears.

Example• extraction of a third molar tooth is to be undertaken a

possible sequel (eg. a risk of one in ten of transient lingual paraesthesia) occurring, would certainly merit a warning to the patient. Patients have a right to know if their lifestyles may be compromised by a side effect of treatment.

• When the incidence of a possible complication is very slight, it is often considered to be in the best interests of the patient not to warn and thus risk frightening the patient, but the significance of the above possibility is very real to a professional singer, for example and a failure to elicit any relevant information about a patient and to warn them accordingly could be legally disastrous.

General Anaesthesia & Sedation• When receiving treatment under general anaesthesia or

sedation, the patient is temporarily deprived of their capacity to give a valid consent to treatment. This makes it all the more important that they understand what is proposed in advance of the treatment because it will not be possible to refer to them once treatment is under way.

• It is also undesirable for the consent process to be carried out immediately prior to the administration of the anaesthesia or sedation, because patients are likely to be preoccupied with or anxious about what lies ahead.

• Ideally, the consent process should take place at a prior visit

Legal Implications• the patient was given sufficient and appropriate information on all

aspects of the procedure • the information was provided in such a form that the patient could fully

understand it • the patient, before consenting, had sufficient time to deliberate in an

unfettered way on the relevant information • all possible complications, their frequency, the degree of incapacity

they may cause and the possibility of permanence, were fully outlined in a way that the patient could completely understand

• the cost of treatment was fully outlined and understood • the patient’s expectations of treatment outcomes were realistic • an appropriate referral was offered • an appropriate diagnosis was established • an accurate medical history was established and appropriately

accounted for in treatment

Key notes• Before examining, treating or caring for competent adult patients,

their consent must be obtained.

• Adults are assumed to be competent unless demonstrated otherwise. If there are doubts about their competence, the question to ask is: ‘Can this patient understand, retain and then weigh up the information needed to make this decision?

• Patients may be competent to make some health care decisions, even if they are not competent to make others.

• Giving and obtaining consent is usually a process, not a one-off event. Patients can change their minds and withdraw consent at any time.

Referral

Treat by a GDP or refer patients to a specialist

Dentist’s expertise

Patient related factorsAgeCooperationAnxiety statusMedical & risk factors

Case complexityDisease severity & extentNon-responsiveMultidisciplinary plan

Referral letters• Key information to include in a referral letter:

Key notes• Patient may be referred for an opinion and treatment plan or

for treatment• Referral letters should contain key facts about the patient and

the condition• Previous relevant radiographs should be made available to the

specialist where possible• The GDP should be advised on the specialists findings,

diagnosis and treatment plan and eventual plan for care when the patient is discharged back to the dentist.

Thank you

References

• Australian Dental Associations Guidelines for documentations and record keeping

• Guidelines record keeping 2008.Royal College of Dental Surgeons of Ontario.

• Griffith University School of Dentistry and Oral health, Dental clinical manual, 2009.

• Dental advise series. 2-Consent, www.Dentalprotection.org• Medical Problems in Dentistry- C.Scully. 7th Edition, Chapter 2.• Periodontolgy at a glance-Chapter 43 “the decision to treat or

refer a periodontal patient” 2009.• Guideline on Record-keeping, American Academy of Paediatric

dentistry, 2007.