Autonotes are used to make it easier for clinicians to record the routine advice they give patients after certain treatments.
They can save time when completing the records, but it's important they reflect the advice given to each individual patient.

Over the years, we have been notified of incidents where the use of autonotes to record information in patient records has led to an inaccurate account of what happened at the appointment.

Some examples might include:

"crown checked" after an onlay was fitted
"patient advised to be careful not to bite tongue" after LA given in the upper arch
"patient warned about contraceptive pill" to a male patient being provided with an antibiotic.

Things to consider

If an identical entry is made in every record - such as, "examination, medical history checked, at the start of every entry, or "patient understood/agreed/happy" at the end - it can undermine the integrity of the whole record.

Inaccurate and or repetitive entries may also make it difficult to justify what information was actually given to an individual patient if a complaint or claim later arises, making it more difficult to defend.

Using automatic templates from drop-down menus is not in itself wrong, and some clinicians may enter automatic templates ahead of future appointments to save time, with the intention of amending the record later.

While they may anticipate what treatment they plan to provide, for safer patient care, it is vitally important to complete only the record of the treatment provided, and the discussion had with the patient at the time of the consultation.

NHS England has published examples of record keeping templates in its publication, Dental Record Keeping Standards: a consensus approach.

DDU advice on record keeping best practice

If you're planning to use autonotes, it's important to tailor the entry to the individual patient.

If you're using them as a memory aid to make sure patients are given all the relevant information, it may be more appropriate to have a checklist for the information to be provided before, during and after certain treatments, rather than an automatic entry for the records.

When completing patient records, make sure that:

all records are contemporaneous, clear, concise, and complete
they are individual to the patient and accurately reflect the nature of each appointment
extra care is taken when using automatic templates to ensure the correct information is selected
if electronic records do need to be modified, record the date and time of the modification, and make it clear who made it
for dento-legal purposes, 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 when any modifications made.

See our introduction to good record keeping for more information.

Using templates and autonotes in electronic records

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