Dr. Candace DeLapp, the former executive director of the Trust use to say:
“Your clinical notes are like a fire- they can either keep you warm on a cold night or burn your house down.”
It’s a simple statement, but it captures one of the most important principles of professional liability: your clinical records can become either your greatest asset or your worst enemy.
Your memory isn’t a defense, your records are.
Imagine receiving a board complaint or request for records on a pending lawsuit about a patient you treated several years ago. You may think you remember the patient, the procedure, the conversation had, the details… but truth is if isn’t written in your records… it didn’t happen.
You won’t remember every detail. That is why throughout documentation in your clinical notes are imperative. You can review it line by line, detailing the encounter.
When a complaint arises, your clinical notes can help tell that story of what really happened. What you diagnosed, what you recommended (alternative treatment and risk of no treatment), what you discussed with the patient, ultimately what the patient chose, what treatment was completed, complications or adverse outcomes, follow up, referrals, and patient’s demeanor.
If it isn’t documented… it didn’t happen. It’s that simple
If you don’t document details then it didn’t happen. It becomes a simple she said vs he said.
Good notes tell a story of the patient’s care.
“Crown placed. Patient tolerated procedure well.” Is not a good story and will often be that fire that burns your house down should a complaint arise.
A good clinical note should provide enough meaningful information that another dentist, attorney, investigator, or licensing board, can understand the whole scope of care.
A good documentation could include the following:
- Patient’s presenting cheif complaint
- Clinical and radiographic findings
- Your diagnosis and differential diagnosis
- Treatment recommendations, alternatives, and risk of no treatment
- Risks, benefits, and potential complications
- Patients questions and concerns
- Patients decision to accept, delay, or decline treatment
- Informed consent for procedure both verbal and written
- Relevant medical history and medical history changes
- Blood Pressure
- Detailed Anesthetic amounts administered including amounts of epi
- Details of procedures performed
- Post op instructions given
- Risks post operatively
- Referrals or consultations
- Follow up recommendations
- Significant communications with the patient
Avoid a “CYA” note. Good documentation includes “just the facts”. Avoid judgmental, inflammatory, or emotional language.
NEVER ALTER THE STORY AFTER THE FACT.
If you realize you forgot something or want to add to your clinical notes at a later date, follow your electronic health records proper procedure for adding an addendum to the note. DO NOT go back and rewrite the original note as though it had been entered contemporaneously.
The integrity of your notes matter. A transparent late entry can help clarify the record. An altered record can create an entirely different and worse problem.
Keep your fire burning for you.
Dr. DeLapp’s famous words are worth remembering every time you sit down to finish your notes:
Your clinical records can keep you warm at night or burn your house down.
Take a few extra minutes. Document the findings, recommendations, conversations, patient decisions, care, and any communication that is relevant.
Because years from now, when you may or may not remember exactly what happened, your notes will be there to protect you.
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