The Dental Defence Union (DDU) has today provided guidance on amending clinical records, in the latest edition of its journal.
The DDU argue that having good-quality and contemporaneous records puts dental professionals in the strongest possible position to evidence and support their clinical assessments, diagnoses reached, decisions made, as well as any advice and treatment given. If records are amended retrospectively without making clear this has been done, it can undermine their credibility in a complaint, claim or regulatory matter.
The DDU understands when a clinician receives correspondence regarding a complaint or claim, the first instinct is to review the records of the patient in question. However, amending records retrospectively without making it clear that it was done at a later point in time can backfire. It can lead to an allegation that the clinician was dishonestly representing what happened.
Greta Barnes, senior claims handler at the DDU explains: “Sometimes it is not possible to complete a note due to time constraints, IT issues or unexpected urgent appointments. If you do not have time to complete a note during the appointment, you should do so at the earliest possible opportunity and clearly state the time that the notes or additional notes were written in the records.
“If it is not possible to enter data electronically within a reasonable time period, it is good practice to make a handwritten note of the information so you can transfer it to the system when you are able to. When adding your electronic note, state the date and time that you made the paper note, the reason why you could not make it electronically and ensure the date and time being transferred to the computer is accurate.
“If DDU members have any queries about amending records, they can telephone our advice line on 0800 374 626 or visit the DDU support pages for more information.”
Read the full DDU journal here.
