The GDC and Record Keeping - Is Narrative Changing?

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Published: Tuesday, 16 July 2024 09:26
Written by Peter Ingle
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The GDC and Record Keeping - Is Narrative Changing?

“Are you spending a lot of your time taking copious notes and keeping records in meticulous and detail? [sic] Do you feel like your time would be better spent with your patients?”

This was not a comment from a grumpy grey haired GDP, as they read an indemnifiers bulletin advising them to keep better notes. Rather it was the opening paragraph of a recent blog post by the GDC’s Senior Clinical Dental Adviser, Shamir Mehta. This is not his first comment on trends in record keeping. In a recent webinar discussing likely changes to the Standards he opined that some dentists were making unnecessarily long and complex notes.

Record keeping in dentistry is a controversial issue. Most readers will have heard horror stories where an apparently minor omission in a registrants notes contributed to their problems with Fitness to Practice. “If it isn’t written down it didn’t happen” and the default of FTP panels preferring the recollections of complainants to registrants, have dramatically changed the volume of records that dentists make. Shamir Mehta has now attempted to clarify GDC expectations on what is professional, reasonable and in the interests of patients, and what was described as the GDC’s “pragmatic and proportionate approach to reviewing patient records.”   

Dr Mehta began by stating that records did not need to contain every single detail, but they did need to be clear and complete. In the early stages of dealing with a clinical concern, the GDC will usually involve a clinical adviser whose investigation is often based upon an assessment of the records and excludes an actual examination.

To quote Dr Mehta: “Clinical advisers, like me, must carefully draw on their knowledge and experience of the matter and consider the circumstances, while at the same time refraining from opining against the ‘gold standard.’ The clinical adviser’s overall opinion may be influenced by appropriate authoritative guidance and the available professional standards.”

Clinical advisers will be looking at pre treatment aspects and attainment of consent, treatment and (where relevant) aftercare.

It is worth noting that any criticism by clinical advisers, “associated with a failure to meet the reasonably expected standards will be determined by the level of departure, and by the severity of any (potential) harm caused.” Dr Mehta states that a current medical history is essential, whereas the absence of social and past dental histories, in the absence of risk or harm, would receive less criticism.

The argument that there is an acceptable zone in record keeping bounded by problems both with having too little and too much is advanced: “Superfluous and voluminous documentation that lacks any further material importance is not expected, and to an extent, could be a misuse of precious resources and (clinical) time.”

As a guide, Dr Mehta writes that: “For a routine case in a general practice setting, it is ideal to record:

  • a clear or differential diagnosis
  • a logical treatment plan, and in the least
  • risk assessment outcomes for dental caries, periodontal disease and oral cancer.

In the absence of an explicit record for these aspects, it may be difficult for the clinical adviser to be overly critical if it is clear that they:

  • have been suitably undertaken and the outcomes can be determined from an otherwise satisfactory set of patient records
  • the likely findings have been appropriately applied, and
  • the care plan is supported by a written treatment plan.”

Advice on consent is that it should:

  • be documented accurately and concisely.
  • include a record of any relevant alternatives and perhaps your recommended option.
  • provide clarification about the arrangements under which the care is available (NHS or private).

Dental teams looking towards AI for assistance, and those using templates should not assume that this will be enough: “Diligence is also required with the effective use of auto-notes and record keeping templates, where inadequate use may risk raising some doubt about the credibility of the overall record. Documentation prepared by others in the dental team must also be carefully reviewed and finalised, clearly signed and dated.”

As regards actual treatment: “the clinical adviser will aim to appraise the available evidence to verify the adoption of a reasonable and logical approach to support the provision of good quality care, delivered in a safe and effective way. This may include any advice given, drugs prescribed, and the treatment execution (including post-operative instructions etc.). The clinical adviser will also normally consider the alternatives (such as the reasons for the premature failure of a restoration), as well as any specific challenges encountered, which you should record.”

Record keeping does not end there, since any aftercare provision, “including any effective and constructive complaints resolution, being open and honest, and the offering of a timely apology, should be carefully documented, and appropriate aspects kept distinct from the main body of the records.”

Dr Mehta explained that the approach he outlined has been in use at the GDC since 2017. There has been a reduction in the volume of single patient clinical concerns progressing beyond the earlier stages of a fitness to practise investigation. Over the past five years, there has been an overall progressive reduction in the number of concerns reported, and number of cases progressing to a substantive hearing has also gone down, despite the increased numbers on the register.

The former dental chief of indemnifier MDDUS, Stephen Henderson, was not entirely convinced. On X he wrote: “I’m concerned this article perpetuates the unreasonable view that records should meet the @CGdent/@FGDP_UK aspirational standard.” He felt that the GDC needed to look again at the subject.

In contrast, regulatory lawyer Andrea James, noting that almost every GDC case included allegations pertaining to inadequate record keeping, described the GDC blog as “very worthwhile.”

Dental record keeping: what is professional, reasonable and in the interest of patients? (gdc-uk.org)

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