Inadequate record keeping by dental practitioners

L F Brown

When a dental practitioner is brought before a disciplinary body, a common finding is that the 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. This paper examined recent cases reported in the State of Victoria that have involved dental practitioners, specifically seeking those cases where the record keeping was found to be inadequate. It looked at the rulings of these cases with regards to orders made in respect to record keeping. Complaints and notifications specific to dental record keeping accounted for less than 2 per cent of formal complaints. And yet, up to 75 per cent of recent 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 hand writing or typing entries into patient records may be part of the problem. 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. This article is protected by copyright. All rights reserved.