ethical and legal1 Flashcards
clincal negligence claims
3 key reasons for
duty of care - negligence
causation of harm
breach of duty
diagnositc faults leading to dental negligence claims
4
delayed dx
error
improper investigation
failure to act on results
tx faults leading to clincal negligence claims
6
error
avoidable delay
unexpected pain
complications
competence
confidence
preventative faults that lead to clincal negligence claims
3
failure to provide prophylactic tx
inadequate follow up
inadequate post op advice
other faults that can lead to clinical negligence claims
communication
system failure
equipment failure
team failure
why are good records important
Narrative of a pt’s care
Chronology of investigations, findings, advice and tx
Assessment of disease progression
Radiographic comparisons
Record of past tx/tx planned
Audit tx outcomes
Regulatory requirement
* GDC standards of the dental team
* NHS terms of service obligation
Defence in complaints, litigation and hearings
Records written with expectation 3rd parties will see them
quality of records reflects
quality of care
by courts, pt solicitors, GDC
GDC Standards and FGDP (UK) record keeping guidance
16
- personal information
- medical history
- reason for attendance
- charting
- examination notes (including findings from special investigations etc)
- radiographs
- photographs
- study models
- Note of dx - inc perio
- tx options - discussion with pt, pros/cons, accpeted/declined
- evidence of consent and agreement to tx plan
- tx plan stages
- tx notes - inc LA
- lab prescriptions and manufacturer statements for prosthesis
- payment history
- correspondence (incoming and outgoing)
audio-visual recordings (if they exist)
medical history recording
several methods
electronic signature
scanning handwritten form
updates written as entries to notes
ensure consisitent and reliable system in place
records must be
contemporaneous
(at the time, Accurate, complete, logical, clear, concise, legible and easily understood by a third party)
If mishap during tx e.g. a fractured file root – the records must show that the pt has been informed
* The records should contain full details of the incident – the consequences of not doing this can be significant
what to record for radiographs
4
which radiographs taken of what teeth?
justificaiton for them
need to be identifiable and dated
radiographic report
periodontal assessment and monitoring records should include
5
periodontal screening BPE
periodontal dx
periodontal tx plan
OHI given (per appt)
note specific advice - lose teeth, details of pt motivation
common allegations in perio claims
- Was unaware of periodontal disease
- Unaware of extent and implications of the periodontal problems unexplanined
- Inadequate explanation of disease along with the tx options and appropriate advice
- Lack of communication about seriousness/teeth with poor prognosis
- Let down by lack of advice
how to get consent
involves ensuring the pt has the information they need to make a decision about what tx or procedure (if any) they want
All reasonable tx options, along with their implications should be discussed with the pt
Material risks for each options should be included
Valid consent means that there should be no ‘surprises’ for the pt about their tx
* E.g. failure to warn of a specific risk, specific risk eventuates, pt would have not undergone tx has the warning been given
record notes on discussion and then final consent signed
what not put in records
- Anything you wouldn’t want read out in public that would cast you in an unprofessional light
- Anything insulting or defamatory
- Inaccurate factual information
- Jokes/old fashioned acronyms
- Inappropriate personal comments about the pt
- Derogatory comments about colleagues or their tx of the pt
- **Complaints correspondence – should be kept in a separate complaints file **
- Any advice or letters from you indemnity organisation or even the fact that you called them (inc advice given to you)
