Inadequate record keeping by dental practitioners. 2015

L F Brown
School of Dentistry, The University of Queensland, Brisbane.

When a dental practitioner is brought before a disciplinary body, a common finding is that dental records were poorly kept and inadequate to establish issues of consent for treatment or the nature of the treatment undertaken. Often this finding may be incidental to the actual issue that brought the practitioner before a regulatory body or the Courts. The aim of this study was to examine recent cases reported in the State of Victoria involving dental practitioners, specifically seeking those cases where the record keeping was found to be inadequate as an incidental finding. Published rulings of formal complaints and notification cases brought before disciplinary hearings in the State of Victoria for the period January 2000 to June 2014 were analysed with regards to orders made in respect to record keeping. Complaints and notifications specific to dental record keeping accounted for less than 2% of formal complaints. And yet up to 75% of cases have made a finding of unprofessional conduct against a dental practitioner on the basis of inadequate record keeping, most often in combination with other breaches of conduct. Adherence to the traditional format of handwriting or typing entries into patient records may contribute to the problem of poor record keeping in a clinical dental setting. Newer technologies such as digital intraoral and extraoral photography and audio-recording of patient interactions may offer a solution to the problems of record keeping.

UI MeSH Term Description Entries
D011785 Quality Assurance, Health Care Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Assessment, Health Care,Health Care Quality Assessment,Health Care Quality Assurance,Healthcare Quality Assessment,Healthcare Quality Assurance,Quality Assessment, Healthcare,Quality Assurance, Healthcare,Assessment, Healthcare Quality,Assessments, Healthcare Quality,Assurance, Healthcare Quality,Assurances, Healthcare Quality,Healthcare Quality Assessments,Healthcare Quality Assurances,Quality Assessments, Healthcare,Quality Assurances, Healthcare
D011795 Surveys and Questionnaires Collections of data obtained from voluntary subjects. The information usually takes the form of answers to questions, or suggestions. Community Survey,Nonrespondent,Questionnaire,Questionnaires,Respondent,Survey,Survey Method,Survey Methods,Surveys,Baseline Survey,Community Surveys,Methodology, Survey,Nonrespondents,Questionnaire Design,Randomized Response Technique,Repeated Rounds of Survey,Respondents,Survey Methodology,Baseline Surveys,Design, Questionnaire,Designs, Questionnaire,Methods, Survey,Questionnaire Designs,Questionnaires and Surveys,Randomized Response Techniques,Response Technique, Randomized,Response Techniques, Randomized,Survey, Baseline,Survey, Community,Surveys, Baseline,Surveys, Community,Techniques, Randomized Response
D003792 Dental Records Data collected during dental examination for the purpose of study, diagnosis, or treatment planning. Dental Record,Record, Dental,Records, Dental
D003815 Dentists Individuals licensed to practice DENTISTRY. Dentists, Pediatric,Dentists, Prosthetic,Dentists, Restorative,Periodontists,Prosthodontists,Dentist,Dentist, Pediatric,Dentist, Prosthetic,Dentist, Restorative,Pediatric Dentist,Pediatric Dentists,Periodontist,Prosthetic Dentist,Prosthetic Dentists,Prosthodontist,Restorative Dentist,Restorative Dentists
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D014739 Victoria A state in southeastern Australia, the southernmost state. Its capital is Melbourne. It was discovered in 1770 by Captain Cook and first settled by immigrants from Tasmania. In 1851 it was separated from New South Wales as a separate colony. Self-government was introduced in 1851; it became a state in 1901. It was named for Queen Victoria in 1851. (From Webster's New Geographical Dictionary, 1988, p1295 & Room, Brewer's Dictionary of Names, p574)
D017410 Practice Guidelines as Topic Works about directions or principles presenting current or future rules of policy for assisting health care practitioners in patient care decisions regarding diagnosis, therapy, or related clinical circumstances. The guidelines may be developed by government agencies at any level, institutions, professional societies, governing boards, or by the convening of expert panels. The guidelines form a basis for the evaluation of all aspects of health care and delivery. Clinical Guidelines as Topic,Best Practices,Best Practice
D019983 Guideline Adherence Conformity in fulfilling or following official, recognized, or institutional requirements, guidelines, recommendations, protocols, pathways, or other standards. Institutional Adherence,Policy Compliance,Protocol Compliance,Adherence, Guideline,Adherence, Institutional,Compliance, Policy,Compliance, Protocol

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