Some practices use autonotes (a pre-set phrase) to make it quicker and easier for dentists to record the routine advice they give patients after certain treatments.
However, using autonotes to record information in patient records can 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 part of the mouth.
Similarly, identical entries in every record (eg, 'patient understood/agreed/happy' at the end of every entry) can make it difficult to justify what information was actually given to a patient if a complaint or claim later arises.
Autonotes should also not be entered into a record in advance of a future appointment.
Whilst using autonotes is not in itself wrong, for safer patient care you should consider the following points.
- 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 an automatic entry is a memory aid for the clinician to provide patients with all relevant information or for the clinician to remind them what needs to be recorded, it might be better to use a checklist or template with a list of headings rather than an autonote.
- The accuracy and integrity of patient records should be maintained at all times.
Examples of record keeping templates are provided by the Dental Record Keeping Standards: a consensus approach published by NHS England and NHS Improvement.
DDU advice on record keeping best practice
When completing patient records, 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 autonotes, 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 when records were created and modified.
See our introduction to good record keeping for more information.
This page was correct at publication on 05/01/2021. Any guidance 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.