Dentists and their teams are required to document everything that happens during a patient appointment. From the results of clinical assessments to the specific oral hygiene advice given, a written record is created and saved. The General Dental Council (GDC) ‘Standards for the Dental Team’ mandate that “as much detail as possible” is included in these patient notes in order to accurately represent the conversations that took place. The same standards also obligate that dental professionals should be aware of how both their tone of voice and body language could be perceived by patients.
This is challenging for even the most diligent dental professional for a number of reasons, not least of which is the inability to completely and contemporaneously reflect the sentiment of conversations merely through the written word. Finding a way to keep a record of such things is important to ensure that clinicians are given credit for the comprehensive way they engage with their patients. In response, dynamic technological solutions have been developed that are changing the game for clinical note-taking.
It's not what you said…
What you say as a professional to your patient, as well as how you say it, are essential considerations within dental consultations. Research has demonstrated that tone of voice significantly impacts how words are construed, particularly emphasising negative or positive connotations. Specifically, within a healthcare setting, effectively using the right tone of voice has also been shown to strengthen patient-professional relationships and enhance the exchange of information.
A 2023 study reviewed the impact of both voice tone and word choice within a medical setting. When doctors emphasised the benefits – in this case about weight loss – in a positive and upbeat sentiment, patients responded more favourably. Professionals whose tone and words took a negative approach and were delivered in a slower way, saw increased hesitation from patients to follow advice. This is why it's crucial to think about what you say and how you say it when communicating with patients in the dental practice.
All of this presents a challenge – how do you accurately record the way information is delivered to the patient during a consultation when keeping solely written notes?
Details matter
To maintain contemporaneous, accurate and complete notes – as per GDC requirements – dental professionals must document as much information about appointments as possible. Writing notes in real time may seem like the best way to achieve this. However, multitasking by healthcare professionals is associated with a lower quality of patient care. Not only is your attention, or that of your dental nurse, taken away from your patient to write notes there and then, but the opportunity for errors and missed details also increases.
The alternative is to complete notes after the event, in the evening, for instance. But this approach has its own issues. For a start, it relies on adding details from memory, which allows crucial details to be overlooked. A study also found that dentists remembered far fewer psychosocial details than technical elements from an earlier consultation, which leads to further loss of clarity, context, and sentiment within the records.
This leads to another major challenge in accurate record taking: When and how do you document details without missing relevant nuances or compromising patient care?
The revolution is here
For many clinicians, relying solely on written record-keeping is a flawed, outdated and inefficient approach to documenting patient interactions and consultations. Digital dentistry has revolutionised many other aspects of the daily workflow, and it can do the same in the clinical note-taking space. It’s time we made the change.
With the right technology and support, it is possible to deliver exceptional patient care while protecting the professional team from potential legal disputes that can arise from inadequate clinical notes. Innovative software now allows you to record every single conversation with every single patient. It provides an accurate representation of what was said and how it was said, documenting the exact wording used in minute detail. What’s more, it does all of this while having nothing but a positive impact on the quality of care provided. Your attention is not pulled away from your patient, and you needn’t worry about what you will or won’t remember later.
How is this possible?
Dental Audio Notes (DAN) makes the documentation of complete, accurate and contemporaneous clinical notes effortless. It provides an audio recording of consultations, so both you and your patient are protected by a genuine account of everything that actually happened. The software optimises the consent, security, privacy and storage of data for the full 11 years required for total peace of mind, allowing recordings to be safely shared with patients to enhance their engagement too. In addition, it is simple to integrate within your existing systems and can be set up and ready to go straightaway.
The future of clinical record keeping
Most dental professionals will agree that dental record keeping can be an arduous process, despite its importance in protecting patients and dentists. Manually creating written records is no longer the best option for clinical notes – modern technology is trailblazing a new approach. Upgrade your processes to streamline your administrative workflow and elevate patient care standards at the same time.