I can almost hear the groans this topic often elicits. Yes, it’s those dirty words again - clinical records. Hang on a minute! Please read on…

Surely we don’t need to be reminded again, I hear you protest. There’s always someone nagging us about it. Yet hundreds of dental claims every year remind us that it’s a topic that’s not going away. Good clinical records are an essential part of contemporary dental practice. As the following claims highlight, good records help protect you against the unexpected.

Adverse patient outcomes

• A dentist referred one of her patients to a colleague for extraction of tooth 44. While the initial conversation was had over the phone, she emailed through a written referral a few days later. However, in preparing the referral, the dentist realised she hadn’t made note in the patient’s record of which tooth was to be extracted. Relying on memory, she wrote tooth 45 in the referral, instead of 44. The wrong tooth was subsequently extracted, causing much embarrassment to both dentists and claims of negligence against them.
• A young woman presented for the extraction of tooth 35. She completed a ‘medical history form’ in the waiting area on which she disclosed her allergy to codeine. While the dentist asked her a number of questions about her medical history, he did not review the form or ask her about known allergies. He subsequently prescribed an analgesic containing codeine. The woman’s mother contacted the dentist a few days later to advise that her daughter had required hospital treatment for an adverse drug reaction. A letter of demand for compensation followed soon after.

Claims of negligence or misconduct against you

• A patient telephoned her dentist after hours to report persistent pain and swelling post procedure. The dentist took the call on his mobile phone while he was driving home from work. He clearly recalls advising the patient to come back in the following day if her symptoms had not settled. However, he did not make any record of their conversation.   As the patient did not return the next day, he assumed her symptoms had subsided. Yet the patient was subsequently hospitalised with a systemic infection and later claimed the dentist was negligent in failing to diagnose her condition. She denied that he had told her to return to the practice the following day if her symptoms had not subsided.

Disciplinary action for failing to meet your professional obligations

• A patient lodged a complaint with AHPRA about the quality of veneers performed on teeth 11 and 21. In investigating the patient’s claim, AHPRA also found the dentist’s record keeping to be seriously deficient. At times he had referred to porcelain fused to metal crowns instead of veneers, and at other times he had recorded the wrong date of the patient’s appointment. Furthermore, while the dentist insists he carefully worked through a process of gaining informed consent to treatment, there was no evidence of this in the clinical record. Therefore, the dentist had the added pressure of responding to further allegations about the appropriateness of his practice.
• A dentist was asked to provide a copy of her clinical records to AHPRA in response to a complaint made about another dentist. While they had both treated the patient over time, there was no complaint about this dentist. Her records were simply required to help the investigators better understand the patient’s course of treatment. Having provided her records, she was shocked to receive notice from AHPRA advising that her records were now the subject of an investigation. Her record keeping was deemed inadequate in that the hand written notes were illegible, not maintained in chronological order and did not include adequate details of the treatment provided.

Why keep clinical records?

Contrary to popular belief, good record keeping is not simply about protecting yourself from ‘being sued’. It’s more important than that. The primary purpose of clinical records is to ensure the safety and continuity of patient care. That is, to record the patient’s unique journey from start to finish. Carefully recording the sequence of events allows you or someone else, to return to the records at any time to clarify the facts behind your decision making. Even a dentist with a photographic memory can’t remember the circumstances of every patient. Who has a known allergy? What did the OPG taken 4 years ago reveal? What did you advise the patient about that broken endodontic file?

Although good clinical record keeping has always been a requirement for health professionals, the Dental Board of Australia has formalised dentists’ obligations by issuing the Guidelines on dental records. Remember, you must be familiar with the guidelines and disciplinary action can be taken against those who fail to comply.

In addition to the Board’s requirements, good clinical records are essential for fulfilling your obligations to funding providers such as government agencies and private health funds. As dentists well know, compliance audits can be onerous and costly for those who fail to comply.

Finally, good clinical records will assist you in defending a claim of negligence or misconduct against you. The old adage of good records – good defence, poor records – poor defence and no records – no defence is no cliché. If you fail to keep good records, disputes will ultimately boil down to the patient’s word against yours. Conversely, you are much better placed if you can demonstrate that good record keeping is part of your usual practice. Not just for the patient in question, but for all of your patients.

Copies of the Dental Board of Australia’s Guidelines on dental records (2010) can be readily accessed via www.dentalboard.gov.au/Codes-Guidelines/Policies-Codes-Guidelines.

What constitutes clinical records?

Clinical records generally encompass any hard copy or electronic information pertaining to a patient’s care. This includes:

• Clinical notes, including any diagrams, photographs or consent forms
• Diagnostic imaging and reports including CAD-CAM restoration files
• Dental models
• Reports, referrals and any other correspondence pertaining to the patient that has been exchanged with third parties. This includes Instructions to and communications with laboratories.

General principles for collecting and maintaining clinical records

What information should be recorded in clinical records?

• Identifying details of the patient
• Details of who the patient would like contacted in the unlikely event of a medical emergency
• Previous and current medical history including any allergies or adverse drug reactions
• The date of each visit and the identifying details of the practitioner(s) providing the treatment
• The patient’s presenting problem and any changes in their condition since their last contact with you or your practice
• Information about the type of assessment, examinations and diagnostic imaging performed
• Your observations, clinical findings and diagnosis
• Proposed treatment plans, associated risks and alternatives as discussed with the patient
• Estimates or quotation of fees
• The patient’s consent to the agreed treatment and proposed fees
• All treatment provided and the patient’s response to that treatment. Include the use of any medicines, prostheses or other products. Did the treatment go according to plan? Did the patient respond as you expected?
• Instrument batch (tracking) control identification, where relevant
• Instructions to and communications with laboratories
• Instructions or warnings given to the patient
• Details of any further exchanges with the patient, or carer, that occurred via telephone, text message or other method
• Any correspondence with other service providers, or third parties, pertaining to the care of the patient
• Any other information you feel is relevant to the continuity of the patient’s care

Achieving good clinical records

While it can be tempting to declare that good record keeping is simply too onerous for a busy dentist, many health professionals do manage to achieve it, dentists included. Arguably, success lies in structuring your processes for gathering and recording clinical information in a way that reduces any administrative burden. Work with your Practice Manager to explore ways in which your record keeping processes could be streamlined.

Consider the benefits of using hard copy or electronic templates for recording clinical information. Ensure they are set out in a way that is easy to use.

• Ensure information gathering follows the sequence of clinical workflow
• Set out relevant headings in the order a dentist is most likely to use them
• Insert prompts to remind dentists to record particular information
• Use colour coding where appropriate, as a visual cue for recording certain information

While it might take some time to set up the practices that work best for you, there are significant benefits to be had, including opportunities for greater business efficiencies.

It is always encouraging to hear that good, comprehensive clinical records can and do assist dental practitioners in successfully defending patient complaints. This case study is about one such positive outcome.

In 2009, the patient lodged a complaint against the dental practitioner with the Dental Board of New South Wales (as it was then known). The patient complained that her health had declined as a result of alleged injuries sustained from implant placement. The practitioner rejected the allegations of complaint and submitted to the Board that his management of the patient had been appropriate and in accordance with established standards of good practice.

In 2010, the matter was considered by the Dental Care Assessment Committee (DCAC) of the newly established Dental Council of New South Wales. The DCAC considered the matter, including reports from the consultants whom the patient had subsequently attended. An independent practitioner also provided an assessment, based on examination of the case records. The DCAC formed the view that the treatment provided was unsatisfactory on the following grounds:

• Failure to record a medical history and patient assessment.
• Incorrect diagnosis and treatment planning, failure to assess bone levels and failure to consider the necessity for bone grafting resulting in unsatisfactory case selection.
• Incorrect placement of implants resulting in perforation of the maxillary sinus and bony floor of the nasal cavity resulting in apparent infection in the maxillary sinus.

The Committee made a recommendation to the Dental Council of New South Wales that the practitioner be directed to refund treatment fees.

The Dental Council sought the practitioner’s attendance before it so that the issues could be ventilated.

At the meeting with the Dental Council in 2011, the practitioner made submissions addressing the grounds above and answered questions from the Dental Council members. The practitioner also supplied the Dental Council with all of his clinical records, radiographs, and other materials.

In the result, the Dental Council decided as follows:

• Council compliments the practitioner on his thorough and excellent records.
• Council does not agree with the decision of the DCAC.
• Council resolves to dismiss the complaint.

The Chairman of the Dental Council specifically commended the practitioner on the quality of his records and said that this matter is likely to be a good teaching tool for the rest of the profession. The outcome is an excellent one for the practitioner and, in our view, the wider profession in that it highlights the importance of good records and demonstrates that good, comprehensive records are important not only in the context of providing good clinical care but are also useful in successfully defending the practitioner against complaints.

For the current requirements in record keeping, practitioners are referred to the “Dental Guidelines on Dental Records” which can be found on the Dental Board of Australia website at www.dentalboard.gov.au.

The case:

The patient commenced proceedings in the District Court following root canal therapy that was performed by the dentist. As a consequence of the root canal therapy, the patient suffered a penetration of his right maxillary sinus cavity leading to infection, chronic right-sided sinusitis, headaches and nasal blockages.

In May the patient presented to the dentist complaining of pain involving tooth 15. The dentist examined the tooth, took an x-ray and subsequently recommended root canal therapy. The records did not contain any findings of the examination and assessment.

Not surprisingly, the dentist did not recollect the consultation with the patient and therefore was not in a position to give direct evidence about what was discussed with the patient. There was no record of a discussion in the clinical record.

The patient alleged that the dentist used sodium hypochlorite solution during the procedure. The dentist’s clinical records did not record the use of any solution. The patient alleged that he noticed pain and swelling in the area where the solution was injected.

The patient re-attended the dentist in June. At this appointment, the dentist completed the second stage of the root canal therapy. The patient did not return to the dentist after this appointment.

Following the treatment, the patient developed severe symptoms in the right maxillary sinus region and was admitted to hospital with an acute epistaxis in September. The patient consulted with two ear nose & throat surgeons who advised that surgical treatment for ongoing infected maxillary and ethmoid sinuses would be required. The patient had tooth 15 extracted in October the following year.

At the time the tooth was removed, the clinical and radiographic evidence indicated that the patient’s maxillary ethmoid sinus condition had worsened. However, the patient was reluctant to undergo surgery because of the risk of possible loss of vision. In this regard he had already lost vision in his left eye and was particularly concerned about the risk of further loss of vision which was reasonable in all the circumstances.

The outcome:

Both parties (dentist and patient) obtained expert opinion in the matter on the following issues:

• Whether it was reasonable for the dentist to perform root canal therapy rather than extracting the tooth;

• Whether the dentist failed to perform the appropriate irrigation technique and use the appropriate instruments during the root canal therapy; and

• Whether the dentist penetrated of the patient’s right maxillary sinus cavity and whether such penetration was below the standard of care.

Based on the x-ray taken in May and the patient’s version of events, the patient’s first expert considered the long-term prognosis of tooth 15 to be poor and therefore argued that endodontic treatment was not a reasonable option in all the circumstances. The patient’s second expert simply noted that the dentist’s reason for performing the root canal therapy was “unknown” as it was not recorded in the dentist’s clinical records.

The dentist’s expert disagreed with the patient’s experts. He considered the dentist’s decision to attempt to save the tooth was reasonable in all the circumstances. The dentist’s expert commented that in general dental practice, the clinical decision as to whether to extract or perform root canal therapy on a tooth is not absolute. Many variables may contribute to a dentist’s decision including the treatment aims, the patient’s desired outcome, the health of the patient, the prognosis of other teeth and financial concerns. Thus, the dentist’s expert did not believe that the dentist “was necessarily in breach of his duty of care in attempting to save the tooth rather than extract it.”

The patient’s second expert believed that the patient’s symptoms of immediate pain & swelling after the injection were consistent with a sodium hyperchlorite injury and that the dentist had failed to take appropriate precautions to prevent such an injury, given the proximity of tooth 15’s apex to the maxillary sinus. The expert said a side ported needle should have been used (ensuring that the irrigation needle was not blind to the root canal during the root canal irrigation) in order to reduce the risk of sodium hyperchlorite injury. The expert considered the root canal therapy itself to be acceptable. However, he considered the dentist’s alleged failure to take appropriate precautions and prevention of sodium hyperchlorite injury to fall below the standard of acceptable practice.

The dentist’s expert felt that the radiograph (which showed that the root apex of tooth 15 was very close to the sinus floor) should have alerted the dentist to the possibility of perforation or entry to the sinus. The dentist’s expert said that the dentist’s “choice of irrigant and irrigating needle syringe may have directly contributed to the sodium hyperchlorite injury”. The expert suggested that sterile isotonic saline should have been used instead, and that the needle used with the irrigation syringe should have been side ported to reduce the pressure of the irrigant in an apical direction, which is this case, was directly towards the sinus itself.

The patient’s first expert opined that it was likely that during or after the root canal therapy at the second appointment that an infection penetrated into the right maxillary sinus due to the proximity of the dental root to the sinus.

A decision was reached to settle this case prior to the hearing. This decision was made because it was difficult to defend the treatment provided by the dentist when his clinical records did not reflect details of the treatment provided. The dentist did not include any details of why the treatment was necessary, the instruments used or the type of solution used for the procedure. The dentist’s clinical notes simply recorded that he had performed root canal therapy.

Lessons to be learned:

• Every practitioner needs to review and follow the Dental Board of Australia’s “Guidelines on dental records”. These Guidelines provide that dental practitioners “must create and maintain dental records that serve the best interests of patients, clients or consumers and that contribute to the safety and continuity of their dental care”.

• In addition to the above rationale, a practitioner’s clinical records are evidence and essential to the defence of a civil claim. In this case the records did not contain any findings about tooth 15 to support the recommendation for RCT. The records did not record any discussion about treatment options. They did not record clinical details about the RCT itself including the solution used. Ultimately the records were of no assistance in the defence of the claim.

Amy Rogerson
Solicitor, Meridian Lawyers

Kate Hickey
Special Counsel, Meridian Lawyers