Automatic note generation can ease time pressures for busy dental professionals but don't let these convenient record-keeping tools undermine the accuracy of your records, says the Dental Defence Union's (DDU's) Eric Easson.

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Technology has an important supporting role in dental practice and automatic templates are a great example of tools that can make life easier. However, it's important not to let your attention slip, or errors could creep in that undermine the integrity of your records.

In particular, the Dental Defence Union (DDU) is aware of cases where automation has led to an inaccurate account of what happened at the appointment, either because the template for a particular procedure has not been fully completed, or because an automatic entry includes standard information which hasn't been tailored for the individual patient.

For example:

  • 'Crown checked' after an onlay was fitted

  • 'Patient advised to be careful not to bite tongue' after LA given in the upper arch

  • 'Patient warned about contraceptive pill' to a male patient being provided with an antibiotic.

The following fictional scenario shows what can go wrong and the possible implications:

A patient attended their practice with severe toothache and after discussion with the dentist it was agreed that the tooth in question, a lower right molar, would have to be extracted. Following the procedure, the patient was left in pain from a retained root and later made a complaint to the NHS, alleging they had not been warned of the risk and that they considered their treatment to be unsatisfactory.

During their investigation, a clinical adviser reviewed the record and found an automatically recorded warning of the risk of root displacement into the maxillary sinus, but nothing to say a complication had occurred. While the dentist's technical skill was not questioned, the adviser criticised them for not checking the entry was appropriate for the individual patient. They were warned this risked undermining the record's purpose as an aid to continuity of care within the dental team. The adverse event prompted the dentist to reflect on their approach and develop a practice protocol on the safe use of automated note-taking tools.

DDU advice

If you want to avoid the pitfalls that can come with automatic templates or auto notes, you and your team should consider the following points.

If a time stamp on a computerised record shows the notes were written before the appointment, it might lead others to question how it can be an accurate reflection of what took place, especially the consent discussion.

Avoid advanced record-keeping

Don't be tempted to get ahead by completing an automatic template ahead of an appointment, with the intention of amending the record later. Even if you have an agreed treatment plan, this approach goes against the GDC principle1 that records must be 'contemporaneous, complete and accurate'.

If a time stamp on a computerised record shows the notes were written before the appointment, it might lead others to question how it can be an accurate reflection of what took place, especially the consent discussion.

Take extra care when selecting from drop-down menus or drag-and-drop lists

The use of automatic templates from drop-down menus is not in itself wrong, but errors can slip in if you are distracted, or you allow it to become something you do automatically without carefully considering the content of each note.

Always review your selections before saving an entry to ensure they are relevant and accurate.

Tailor each entry for the individual patient

Entries like 'examination, medical history checked, BPE recorded' or 'patient understood/agreed/happy' can appear formulaic if used for every patient who attends for a particular type of appointment.

Treat these as a starting point and follow GDC guidance1 by including 'as much detail as possible about the discussions you have with individual patients', including details of their particular preferences, treatment needs and advice given.

Don't rely on templates for consent

If treatment occurs over more than one appointment, it is important to view consent as a continuing process founded on dialogue with the patient and not a single event. Although they can prove to be a useful memory aid to reduce the possibility of omissions, try to avoid working through an automatic record template without careful consideration and make sure your discussions are specific to the patient and the proposed treatment.

If you need a memory aid to ensure patients are provided with all the relevant information, such as complications or advice, it might be more appropriate to have a checklist for the information to be provided before, during and after certain treatments.

However, as the GDC makes clear,2 it's the dental professional's job to 'find out what your patients want to know as well as what you think they need to know' and to 'document the discussions you have with patients in the process of gaining consent'. If you rely on a standard template, you could miss something an individual patient sees as a cause for concern.

Ensure there is an audit trail

For dento-legal purposes, software should be capable of producing hard copies of records and radiographs and of producing a full audit trail of when records were created, who created an entry, and any modifications made.

Check records follow current guidance

Whether or not tech is used, it makes sense for practices to carry out regular audits of clinical records to ensure they meet accepted standards. For example, Clinical examination and record-keeping: Good practice guidelines3 from the College of General Dentistry.