Will your patient records help you provide a high standard of patient care and keep you safe when the regulators come calling?
Keeping good patient records is vital to enable clinicians to provide a high standard of patient care and it is imperative for risk management. It is also an integral part of being able to demonstrate that valid consent was obtained.
Poor record keeping can leave the whole team vulnerable in the event of a complaint. A lack of clear information about care and treatment in the records means a team member who is trying to respond to an unhappy patient has little or nothing to go on, meaning a simple complaint can escalate very quickly if answers are not forthcoming at the time of the incident.
Despite a clinician’s best efforts to ensure that patients are satisfied with their treatment, from time to time complaints will arise.
Without reference to accurate, comprehensive records that have been made contemporaneously a clinician will be heavily disadvantaged in responding to clinical complaints and defending allegations. Detailed records of treatment can make the difference between robustly defending or needing to settle a case.
The Regulators
The General Dental Council, the Care Quality Commission and NHS England are all concerned with standards of patient record-keeping. Lawyers representing a patient in a potential litigation case may also ask to see the patient’s record so it’s imperative to ensure that your records reflect current standards of patient record keeping.
The GDC, NHS England and lawyers usually only become involved in scrutinising patient records if there is some kind of issue. The ‘issue’ could come from a number of different sources e.g. a patient complaint, a whistleblowing or because the clinician has come to the attention of the regulator for some other reason.
The CQC on the other hand is mandated to collect evidence that a practice provides care that is safe and effective, that they are caring and responsive to their patients’ needs (including complaints) and that they are well-led. Patient records form an integral part of the assessment a CQC inspector will make when inspecting your practice.
Faculty of General Dental Practice (UK)
All the regulators will expect clinicians to keep records in line with guidance provided by the Faculty of General Practice (UK) in their standards guidance ‘Clinical Examination and Record Keeping: Good Practice Guidelines’.
Introducing our first ever ‘course bundle’: Patient Records
Patient Records Online CPD
All clinicians are trained to keep good records at Dental School. Time pressures often intervene, and bad habits are easy to acquire so sometimes it’s good to go ‘back to basics’ and be reminded of:
- The benefits of keeping good patient records
- The pitfalls of keeping bad records
- What can happen if it all becomes ugly and litigation is a consequence
Apolline is proud to present four comprehensive new online courses on Patient Records to support the professional development objectives of our clients and members and to help navigate this often very challenging subject. All modules follow FGDP(UK) guidelines.
Patient records is a vast subject area, so to make it manageable we have broken the topic down into 4 distinct modules that work independently of each other as stand-alone courses or as part of a structured programme of learning.
The Course Modules
Module 1: ‘The good, the bad and the ugly’ covers…
- Regulatory requirements
- The benefits of keeping good records
- The pitfalls of keeping poor records
- Security and storage of patient records
- Retention periods for patient records
- The benefits of working with a trained nurse
Module 2: ‘What does good look like?’ covers…
What you should record for:
- All clinical examinations
- All interventions undertaken in clinical practice.
Module 3: ‘Gaining valid consent to treatment’ covers…
What patients need to know before they can give consent that is valid, including:
- What valid consent is and what it is not and;
- How much information you should record.
Module 4: ‘Referrals’ covers…
Everything you need to know when referring a patient for advice or treatment.
The courses contain 3 hours and 30 minutes of verifiable CPD and are suitable for the whole dental team
Upon completion of each courses you are awarded a certificate and reflective learning.
The courses are available to purchase as a bundle or you can purchase each course individually.
