In the internet age, records have never been easier to create and share. Online you can find text, videos, digital images, sound files and every combination of these. None of these formats are complete; none of them provide a perfect reproduction of the event which they attempt to record – they are necessarily selective. When creating a record of any event, the limitations of the technique need to be considered so that when selecting the medium to use, it reproduces the original event in sufficient detail for the intended purpose. As new technologies offers improved alternatives or the demand for an improved quality of recording arises, so the nature of those recordings will change.

Dentistry, like medicine, has always required the clinician to keep records and traditionally these were on paper. The earliest records were little more than accounting devices mainly for the benefit of the practitioners and their charges to patients. But as medicine and dentistry accumulated a scientific evidence base and treatment planning evolved to incorporate it, the need to record the logic behind a particular treatment decision, made the clinical record even more essential. Initially these more detailed records were still for the benefit of the practitioner. Writing them took time that could otherwise be devoted to earning fees. As a result only brief notes, abbreviations, key findings and treatment annotations would be found in most records.

With the rise of consumerism there was a need to explain treatments if they were to ‘sold’ to patients, so the records were expanded to give a fuller account within a more detailed entry on the patient’s record card. At the same time many clinicians adopted a defensive approach in their record keeping by defensively recording additional details to refute any potential claims by the patient.

There was a realisation that not only positive findings should be preserved and recorded but also that negative findings might be important. Gradually paper records had expanded sufficiently to provide a good written portrait of the course of treatment as it progressed.

During the transition which saw these developments being adopted by the dental profession, other records started to become important. Radiographs and models were now recognised as an integral part of the record and for many years radiographs were taken with alarming regularity and not always for clinical reasons. Some third party funding systems actually required radiographs to be taken for monitoring purposes, whether or not they were clinically justified.

Computers

During the 1990s, paper records were increasingly replaced by computerised versions. Many practitioners who wanted to simplify their clinical life and administration saw computers as an easy way to keep records and the sparseness of details on early computer records was notorious. These gradually gave way to much more detailed versions of a clinical record as the software was developed to allow the clinician to add details from drop down menus, along with other prompts that prevented the clinician from leaving the page until all relevant details had been entered into the computer.

Patients in many countries were given rights to access their personal data. This was perhaps the final catalyst to ensure that the dental team created records that were routinely full, accurate and contemporaneous. Many practitioners added pictures, videos, and other digital information to improve the quality of their records.

Tools for improvement

If sufficient detail is recorded at the time of the treatment, the dental record should now do what the name suggests and record a patient’s dental history. To be good the records should, provide the following information, so that even if the practitioner were to be removed from the scene, the dentist who takes over should;

• Know what had been discovered about the patient.
• Know what had been decided with the patient.
• Know what had been done.
• Know what still needed to be done.

Practitioners wishing to improve their own practice could make no better start than to audit the standard of their record keeping. An audit, based on the four ‘need to know ‘areas listed above, will lead to other areas of practice which are needed to support these four aspects of the clinical record. Dental Protection offers its members the tools for such audits through a series of audit frameworks. Exercises in Risk Management can be downloaded from the risk management section of the website.

Without a thorough examination it is impossible to record the baseline condition. But if the level of record keeping becomes both detailed and accurate it provides an opportunity for the same records to be used for clinical governance within the practice. An audit of the clinical outcomes for example may well influence what the practitioner considers to be evidence-based dentistry.

The reverse is also true and it may well be discovered that the results from some treatments are not statistically favourable so the practitioner may want to consider how they currently provide treatments such as endodontics or radiographs. A practice which undertakes a full programme of self analysis will find records of immense use in motivating the whole team to adopt a philosophy of continual improvement.

A defence

Dental Protection deals with many cases both of alleged negligence and disciplinary matters where the quality of the records is of key importance in defending a member. Good records mean that a practitioner does not have to rely on unaided memory but has a true recording of what occurred. To be of use, however, that record must be able to describe exactly what happened in the past, and why.

Not only do records form the basis for improvement, they also help to keep practitioners safe.

Based on an article featured in the Dental Protection 2009 Annual Review