A dentist or hygienist will spend a reasonable chunk of a working day writing dental records. It is quite often listed as a one of the most frustrating and least rewarding parts of the healthcare professional's workload; Despite this, it is something that it pays to be diligent at.

In this article, we will first focus on why we write dental records in the first place. We will then cover how to write good dental records. Finally, we will cover the practical changes you can implement to make this process as quick and easy as possible, without compromising on quality.

Why we write dental notes

As a dentist, it can sometimes feel that writing really thorough dental records comes at a cost of reduced quality of care for your patients. It can reduce the amount time that you can spend with each patient, reduce your level of focus on the patient conversation, or reduce the number of patients you can see in a given time.

Keeping thorough notes falls into the professional responsibilities we agree to when we first join the profession. For UK based dentists, this is covered in Principal Four of our GDC Standards “Maintain and protect patients’ information”, although dentists internationally will have a version of this.

‍

But agreeing to a standard is not the same thing as understanding the value of the record keeping process. It is therefore valuable to remember some of the reasons why we write notes; and the positive impact this has on patient care.

Firstly, and most simply, it serves as both a reminder of what we have previously discussed with the patient as well as serving as a record of treatment. This can reduce repetition of work, eg conducting the same test or discussing the same risk, therefore making the care we provide more impactful for the patient, but also it can make life so much easier for ourselves.

Another important reason for writing notes is if the patient is being seen by a different clinician. Again, this allows continuity of care for the patient, and allows the other clinician to pick up where you left off rather than having to repeat work already done. The next reason, which is often seen and felt as the main reason, is legal protection. This consideration has ballooned in the dentists’ mind over the last 10-15 years, and the environment we work in has become increasingly litigious.

To add to this, there has been a sense in the dental community that regardless of what occurred, there is little defence for the dentist. As such, there has been an explosion in the amount a dentist writes, and this can be seen quite clearly when comparing dentists of different generations.

Due to the fact that the level of detail to which notes are interrogated is so high, should there be a complaint, no level of detail feels sufficient. The negatives of this change are endless. In addition to the abject anxiety this causes for dentists, it is arguably reducing the quality of notes, and the information that can be easily gleaned when a patient is returning for treatment.As such, there are outcomes of clinical note taking which actually help the dentist and the patient, ensuring relevant information is easily seen and understood, whether that is by yourself, or another dentist viewing your records.

What dental notes need to include

At dental school we are taught a structure to follow when writing our clinical notes for a consultation, and it is likely to be a variation of;

• Pt C/O (Patient complains of)
• HPC (History of presenting complaint)
• MH (Medical history)
• SH (Social history)
• DH (Dental history)
• EOE (Extra oral exam)
• IOE (Intra oral exam) to assess oral cancer risk
• Dental exam
• Special tests
• Radiographs
• Diagnosis
• Treatment options
• Treatment plan

There are many benefits of following a similar structure. It shows clarity of thought; a clinician is less likely to overlook a stage and therefore it reduces their chance of making the wrong diagnosis.

However, the level of detail that falls into each of these headings will vary massively from clinician to clinician, based on many things including their level of expertise in different areas of dentistry. We therefore have to adjust the level of detail to take our training and further qualification into account. This though, makes it difficult, as there is not one rule for all dentists’.

But there are guidelines for a recommended minimum, and example of this is FGDP guidelines. By way of a reminder this advises minimal essentials (which I have marked with an asterisk) and aspirational information for different appointment types;

Eg Examination Appointment

• Personal Information
• Medical history*
• Reason for attendance*
• Social History
• Smoking
• Alcohol
• Diet
• Dental anxiety
• Examination
• Extra oral examination*
• Soft tissue examination*
• BPE* (A screen for periodontal condition)Initial charting and update of teeth
• Caries*
• Defective restorations*
• Existing restorations*
• Previous endodontic treatment
• Mobility of teeth
• Prostheses*
• Occlusion
• Occlusion abnormality
• Tooth wear
• Recall interval
• Radiographs
• Record and justify radiographs
• Clinical evaluation of radiographs
• Quality of x-rays graded

Within these sections there is a lesson that can be learnt from how doctors write their notes, they follow a SOAP structure: subjective, objective, assessment, plan.

Our notes follow this same structure, with all sections prior to examinations falling within “Subjective”. Here doctors are taught to strictly record the issue in exactly the patients’ words, in doing so you are less likely to build possible incorrect assumptions into your records, and thinking, early in the patient conversation. Practically, this means recording patient issues in patient language.

The “Objective” suggests that what is seen in the initial examination can be stated in whatever language is necessary to clearly and concisely communicate the clinical situation. “Assessment” is the area of the notes where we need to come to our conclusion regarding the diagnosis, and here, we need to include all the information necessary to show we have obtained good consent, before the final section of “Plan”.

Good consent is critical to providing good quality care to patients. It is more slippery than just a signed consent form, or a record of risks discussed, but it is necessary to capture the full explanation and understanding of a dental treatment plan.

To obtain informed consent, we must explain the risks and benefits of no treatment, recommended treatment and all reasonable alternatives. When considering the risks, they can be broken down into general risks, treatment specific risks and patient specific risks. Following this structure will allow you to ensure nothing is missed.

How we can make writing notes easier

When it comes to the practical task of actually writing up our patient record (whether we are doing that at the end of each appointment or the end of the day) there are several things we can do, although more are available to those using electronic records, to make life easier for ourselves, and we will cover a few of them here.

Use clinical note templates (limited to computerised notes)

There are both advantages and disadvantages of using templates, and it’s important to be aware of these before using templates.

The advantage of using templates is simply that it speeds up note taking by allowing you to read through pre-typed information and editing it, rather than typing everything from scratch.

The disadvantage of using templates is that by having to remove certain bits of text that might not be relevant to the patient, there is a risk that the removal of this information may be overlooked, resulting in an incorrect entry. Thus, leaving in irrelevant or incorrect information in your clinical record. If this was then scrutinised, it can cast doubt over the accuracy of the rest of the clinical record.

With this in mind, the use of templates can still be valuable, but several rules should be followed where possible.

1. Put time aside to make sure your templates actually reflect what you do. These are the foundation of your clinical records, make sure they are as good as it can be.
2. Put a recurring calendar entry in your diary every month, to go through and review your templates, and make improvements to the parts of the templates that have bothered you the previous month.
3. Ensure editable variable parts of information is clearly demarcated from the rest of the text, so you can clearly view it when scanning through the notes quickly.
4. Audit your clinical records, with a view of capturing errors left due to the use of templates, and help this guide you to further changes and improvements.

Use the right software (limited to computerised notes)

Be aware of the fact that there can be different types of software that can help with record keeping. They can range from online file sharing software that allows you to store your templates in the cloud, allowing you to access them from multiple practices; to software that will help streamline your templates for you.

Training your dental nurses

‍The relative ease or difficulty of this can vary as it is dependent on multiple factors. In particular, the number of nurses you work with and their willingness to get involved. A good process to follow could be:

1. Arrange an hour meeting with one, or multiple dental nurses if possible, to go through the layout of your notes and the logic behind it.
2. Give clear instructions of how the nurse can help you run more smoothly by helping with your notes, and what types of information you would like captured where, and in what language.
3. Between you, decide on how you can communicate within the appointment. This is important so that your nurse will be able to interpret what you are doing/saying to the patient clearly. Conversely, you will be able understand from your nurse, what needs clarification or more information.
4. Refine your process once a month by reviewing what is working for you both, and what can be improved.

Admin slots

Finally, regardless of which of the other solutions you have implemented, it is crucial you are reflecting on how you are spending your time at set intervals: for example every month or every quarter. By doing this, you can view how many of your appointments you are running late for, what is causing this, are you staying late. If the outcome of this review is running late for appointments, or staying late, it might be worth building admin sessions into your diary.

‍