It’s in the notes

New technology for note taking and data collection is on its way, but in the meantime, it’s worth keeping meticulous notes using currently available methods. By John Burfitt

Take a survey among dentists of what is the least favourite aspects of their job, and the task of note taking and completing patients’ records is certain to score highly.

That attitude, however, is a great dilemma in our increasingly litigious age, as the role of note taking and record keeping has never been more important. With an increase in the number of patient complaints reported by the Australian Health Practitioner Regulation Agency in recent years, detailed notes and records can often make the difference in cases when determining a verdict for or against a dentist.

As former ADA President Robert Boyd Boland commented in a story about complaints in the February issue of the ADA News Bulletin, “good records, good defence. No records, no defence.”

The point is echoed by Dr Phillip Palmer, chairman of the dental management consultancy Prime Practice. “If you say it to a patient, but you didn’t write it up in your notes, then you didn’t say it,” he says. “Without notes, there’s nothing to confirm what you spoke about, what you said and what you did. So, you’ve got no defence.

“Nearly all older dentists I know of used to write unbelievably shorthand-style notes about the procedures, and didn’t go back to complete them. Then they wondered why they were told it was indefensible in insurance or other claims. That does seem to be changing in the current climate.”

While dental records can be maintained in either paper or electronic form, the Dental Board of Australia outlines what is required in the Guidelines on Dental Records. It states details required in notes for each appointment should include the date of the patient’s visit, the name of the practitioner, the complaint they presented with, the examination, diagnosis, procedures conducted, medicines prescribed and treatment plans recommended.

Importantly, the guidelines also state the notes need to be completed as close to the appointment time as possible and they need to be written in such a way that other practitioners can easily understand and act upon them.

“You just have to make the time to do this and do it properly. If spending five minutes wrapping up each patient’s notes at the end of each consultation means you see one less patient a day, then so be it.”—Phillip Palmer, chairman, Prime Practice

“The public these days has much higher expectations than in the past, and are more willing to complain—and not just to you, but to the authorities. So, you need to cover yourself at all times. Not having your notes complete and in full order means you have no defence.”

Professor Heiko Spallek of the University of Sydney’s Dental School believes the future of the process lies firmly with speech recognition software, which will be able to transfer speech from the dentist during the consultation directly into notes that go straight into patient files. He has already worked on a research project with the University of Pittsburgh on this issue. The Speech Recognition in Dental Software Systems: Features and Functionality project concluded that while around 13 per cent of all general dentists with computers at chairside have used speech recognition for data entry, 16 per cent discontinued the method due to technology problems. But he believes once functionality improves, it could spark a revolution in the way notes are recorded.

“It is not yet perfect and still needs to be streamlined, but this is the way we are heading,” Professor Spallek says. “Voice recognition products stand to make things easier for everyone, as it not only will be able to transcribe but also ‘understand’ the information through what is called semantic recognition. It’s just so essential to do the data collection as close as you can to the time the person is in the chair. It means all the vital information is being collected at the time.”

Until the voice recognition systems are perfected, consultant Julie Parker of Julie Parker Practice Success says the most needs to be made of what is currently available. She says learning to work with a system that suits each dentist’s personality type is ideal.

“I have read research from some US hospitals which claim working with a checklist that is already part of the patient record on a computer program is the most effective way for all personality types,” she says.

“It’s just a matter of, at the end of the consultation, having that patient’s file page open and clicking on a range of procedures and discussions that went on during that appointment. Then filling out the rest of the report can pull all that information together.”

Another approach, says Parker, is to have a dental assistant or nurse record directly into a computer or tablet everything that goes on during a consultation. “Then all the dentist needs to do is check the notes are correct, edit them and add to them where necessary, and then sign off and move onto the next patient.”

“Voice recognition products stand to make things easier for everyone, as it not only will be able to transcribe but also ‘understand’ the information through what is called semantic recognition.”—Professor Heiko Spallek, University of Sydney

That’s one approach that Adelaide’s Dr Peter Alldritt, member of the Oral Health Committee, admits he works with.

“While I am talking to the patient as I’m bringing the appointment to an end, my very qualified dental assistant is noting down all the final details,” he explains. “I then edit all the details together, add in anything else important and then sign off on it. I am then confident it’s complete.”

Another method is the use of a Dictaphone, to dictate notes and letters into a recording that a receptionist types into notes and letters, ready for review by Dr Alldritt at the end of the day.

“I talk a lot faster than I write and completing notes that way can save hours later on. I like to know that everything I have written down is so clearly documented that, if there ever was a problem, whoever is representing me would take one look at the notes and say, ‘this covers everything—you will have no issues with records this thorough’.”

Dictating a voice email directly into a smartphone is one very easy way to include all the vital information at the time, and then the dentist just needs to email it directly into their inbox for completion. Julie Parker also says utilising computer software like Quick Notes is popular with many younger dentists she works with.

“They insist Quick Notes is the way to go as it is so fast and effective—it’s like working with a yellow sticky note that then saves directly into your notebook for easy retrieval and filing.”

But what it all comes down to, adds Dr Phillip Palmer, is a matter of time. “You just have to make the time to do this and do it properly,” he says. “If spending five minutes wrapping up each patient’s notes at the end of each consultation means you see one less patient a day, then so be it.

“I can promise that any dentist who has had to go through any kind of litigation will wish later on they had seen one less patient a day and, as a result, had better notes for all their patients.”

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2 Comments

  1. Voice recognition for note taking in dentistry could be a great idea….would save a huge amount of time. the hippa compliance is very important in the US, would love to see something like this soon.

  2. In Australia, the electronic My Health Record will potentially put patients back in control of their dental records via the ability to upload information and corrections (My Health Records Act 2012). So although dentists might produce ‘clean’ records, the patient can upload notes to their My Health Record, including any complaints, under section 73B of My Health Records Act 2012 (which has replaced previous legislation). As a health care profession, it is thus worth remembering that dental records are the patient’s ‘My’ Health Record, rather than simply a legal document.

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