Patient record is vital in making healthcare effective and safe. It also serves to keep up the professional integrity. Maintaining record of patient’s complaints and taking informed consent before starting a dental procedure plays a very important role. It provides all the information about a specific patient that any doctor looking at the record would need to know to treat that patient. Neglecting to document important details can lead to adverse patient outcomes and malpractice suits. Documentation is legal protection for both patient and doctor in the event of disagreement over care.
Important aspects in a Patient’s Record
- Chief complaint of the patient along with history of presenting illness should be documented
- A detailed medical history of the patient should be recorded and written. If patient is taking any medication, it has to be mentioned
- Detailed dental history should be noted
- Personal history including habits, oral hygiene measures currently being practiced
- Family histroy, which may have influence on disease process, which may contribute for diagnosis and treatment plan
- Findings noted from extra-oral and intra-oral examination
- An examination of the affected tooth or teeth should be completed. Both subjective and objective tests should be completed and recorded
- Radiographs of diagnostic quality should be made for better diagnosis and understanding of underlying pathology
- If indicated, laborarotory investigations can be advised and reports should be attached
- Based on all the examinations and laboratory investigations, the final diagnosis has to be done and entered in the record
- Incase there are any differential diagnosis, details of the same are to be recorded
- A proposed treatment plan and options presented to the patient should be recorded
- Informed consent should be obtained and included in the patient’s treatment record
- The treatment rendered, including any medications prescribed, should be detailed in the patient treatment record
- A statement indicating that postoperative instructions and requirements for future visits with the patient or legal guardian should be included in the record
- The provider should always sign the record
- Patient’s or guardian signature should be obtained
Must know points about Patient Record
- All the dental records should be preserved as it can come in need anytime
- The record should be legible
- If any clinical photographs of the patient has been taken with the consent, it should preserved as well
- A review of potential complications associated with proposed alternative treatment options should be mentioned
- The prognosis regarding the success of alternative treatment options should be mentioned
- Never destroy a record, rewrite information, or use correction fluid or paper. The mere appearance of alteration of the record creates an aura of impropriety
- The date should be mentioned without fail during the initiation of recording the patient details
- Medical records are confidential record – they should never be shared without patient consent, except in certain legal conditions.
“Excellence in medical documentation reflects and creates excellence in medical care”
Article by Dr. Siri P. B.
