Automatic templates are drawn up by some practices to make it quicker and easier for dentists to record the routine advice they provide to patients after certain treatments.
However, using templates to record information in patient notes can also lead to an inaccurate account of what happened at an appointment. Examples include:
- 'Crown checked' after an onlay was fitted.
- 'Patient warned about contraceptive pill' to a male patient being provided with an antibiotic.
- 'Patient warned not to bite tongue' after an anaesthetic in the upper mouth.
Similarly, identical entries in every record (eg 'examination, medical history checked, bp recorded' at the start of every entry or 'patient understood/agreed/happy' at the end of every entry) can make it difficult to justify what information was actually provided to a patient if a complaint or claim later arises.
Automatic templates should also not be entered into a record in advance of a future appointment, for example as anticipation of what the dentist is planning to provide as part of the patient's treatment plan.
While the use of automatic templates from drop-down menus is not in itself wrong, for safer patient care you should bear in mind the following:
- If using automatic entries for record keeping, make sure they are tailored to reflect the advice given to each patient.
- Only complete the record of the treatment provided and the discussion had with the patient at the time of the actual consultation.
- If the purpose of the template is to provide a memory aid for patients to be provided with all relevant information, it might be more appropriate to have a checklist for the information to be provided before, during and after certain treatment, rather than an automatic entry for the records.
- The accuracy and integrity of patient records should be maintained at all times.
DDU advice on record keeping best practice
When completing patient records, whether electronic or manual, make sure:
- records are contemporaneous, clear, concise and complete
- records are individual to the patient and accurately reflect the nature of each appointment
- extra care is taken when using automatic templates, so that the correct information is selected
- if electronic records do need to be modified, the date and time of the modification should be recorded and it should be clear who has made the modification.
For dento-legal purposes, computer software should be capable of producing hard copies of records and radiographs, and of producing a full audit trail of record creation and modification.
See our guide to computer-held records for more information.
This guidance was correct at publication 20/08/2018. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.