- Can I log in remotely to write up my notes?
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The short answer is yes, but there are of course risks associated with remote access. For example, there could be issues around confidentiality if you are in public, or have family members around. There could also be issues around data breach if your systems are not accessed securely by authorised individuals. Therefore, if staff are accessing patient records off-site, there must be robust security protocols in place. The lead 'data controller' will have legal responsibility for setting practice policy and ensuring data security, including decisions about who can access records remotely - and how.
It is our advice that you do not routinely rely on remote access, and instead focus on making contemporaneous records. If you are making records in the evening about patients seen earlier in the day, their accuracy could be called into question.
- Do clinical records belong to the practice, treating dentist or the patient?
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The lead data controller for the practice (usually the owner or senior manager) will have legal responsibility for the storage and security of records. They will also have ultimate responsibility for decisions about disclosure. Data processors (usually clinicians and staff) may be able to view and input records but this is not ownership. Patients do not own their records, but they can request a copy and challenge entries.
- Can I use an AI transcription to make patient notes?
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AI transcription software, often referred to as 'ambient scribes', are becoming increasingly popular and can be used to make dental records. However, it is the practice or organisation that adopts AI, not the individual clinician. The practice will need to put in place appropriate AI governance including updating their data privacy notices, updating their practice policies, providing staff training, and thinking about consent and signage. It is advisable to seek patients' express consent before using audio transcription and to do so you will need to be prepared to answer questions about how the system works so that you can ensure 'transparency' and 'explainability'. Lastly, and most importantly, the clinician remains responsible for the finalised entry. It is therefore essential that you check AI generated summaries for accuracy before saving.
Related DDU guidance:
- Should a practice owner tell the treating clinician when they disclose records to a patient or third party?
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There is no requirement for a data controller to notify a treating clinician of such a request - but it is certainly advisable to let them know. Much will depend on the reason for the request.
When it is clear a request relates to a potential complaint or claim, it is advisable to seek dento-legal advice at the earliest opportunity and you can only do so if you know about it.
There are however circumstances when a patient is simply asking for a copy to take with them when relocating and moving practice. In such circumstances, it can be helpful to explain that dental professionals rarely ask for historical records when seeing new patients but if they do need a copy then this can be arranged directly between the practices (with the patient's consent). If in doubt, contact the DDU.
- If I notice a mistake in a previous record entry can I go back and fix it?
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You must not go back and amend historic records. Patients can and do challenge the accuracy of records and practice management software can be interrogated to check if entries have been altered. Altering records could give rise to an allegation of dishonesty at the GDC. If you do later notice an error or omission, the safest thing to do is write a new entry marked as a 'retrospective entry' ideally explaining why it is being made at a later date.
- How do I evidence valid consent?
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The best evidence that valid consent has been obtained is a bespoke contemporaneous record entry that details the discussion that actually took place. Whilst a written consent form is useful evidence that a consent process took place, it is not a replacement for the discussion itself. Read our guide on patient consent.
- Do I need to store a copy of a referral letter if it is available online?
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For both practical and dentolegal purposes, it is advisable to have a copy of all referral correspondence stored within your practice record management system. We have seen a number of cases where a practice or individual has lost access to an online referral platform making it difficult or impossible to retrieve referral correspondence. Such correspondence may be pivotal in defending a complaint or claim but, more importantly, it will be much easier to avoid errors if all the relevant information is readily accessible.
- How long should the practice retain patient records?
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The practice should have a clear data retention policy that sets out how long records will be retained. The timescales will vary depending on a number of factors. The general principles are set out in this DDU guide.
- Are the standards for record-keeping the same in the context of an 'out of hours' emergency appointment?
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The GDC expect all registrants to adhere to the principles set out in GDC Standards for the Dental Team irrespective of where treatment is carried out. GDC standard 4.1 states "You must make and keep contemporaneous, complete, and accurate patient records." GDC-UK.org standards.
- Is it ok for my assistant to make notes during the consultation and for me to then review and finalise them at the end of the session?
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It is acceptable for your assistant to make record entries on your behalf but as the treating clinician you are ultimately responsible for the final entry. It is of course helpful for you to undertake some training with your assistant to ensure they know what information you would like them to capture, and how you would like it to be set out. This can save valuable time, and ensures the details of a consultation are captured contemporaneously.
It is acceptable to review and finalise records at the end of a session. However, the more time that elapses, and the more patients you see, the less likely you will be able to remember the details of earlier appointments and convince a third party investigation that your entry was contemporaneous.