Digital record-keeping is reaching new levels

01 September 2023

Dental professionals need to take notes continuously, keeping record of their patients’ oral health issues, treatment plans and payment schedules. Digital technology has revolutionised this process, allowing the dental team to work faster, smarter and more efficiently than ever before (1).

The advent of electronic records, including digital images and scans, provide safer, quicker and more detailed information than traditional technologies. When data is digital, the dentist and patient can benefit from high quality clinical information, enhanced diagnostic capabilities and more efficient implementation of major treatment plans.

Of course, the fundamental criteria used to manage risk in a dental practice is keeping good quality clinical records (2).

These days, patients are demonstrating a greater interest in their dental care than ever before and demanding greater accountability from their dental practices.

Regardless of the dentist’s equipment, experience or capabilities, it is the in-depth, personal conversation between clinician and patient that has the greatest influence on the appropriate treatment plans being recommended, and what the patient ultimately decides. Being fully present and actively listening is essential to understanding the full diagnostic picture (3). That’s where audio recording software can be a real boon to a practice. 

With dental professionals being required to record ‘complete, accurate and contemporaneous’ notes and with the GDC specifying that you must record ‘as much detail as possible’ (4), it doesn’t get more accurate than a live audio recording.

Using digital devices for note-taking enables dentists to capture what actually happens, not just what gets written up. While written notes are still important – audio recording should be considered as an adjunct, not a replacement –  it does comprehensively erase the dangers of inaccurate note taking. Should a dentist ever be challenged, they will have a complete record, giving them the confidence to respond to any challenge with wise, data-driven and considered actions moving forwards.

Aside from them being a verifiable record of the consultation, audio recordings take the stress away from the dentist or dental nurse of having to try and write everything down. Knowing the consultation is being recorded enables the dentist to fully focus on the patient, making the most of the limited, valuable time of an appointment. So patient care is positively impacted.

The accuracy of audio recordings can prove particularly useful in a busy practice where a patient needs follow-up or emergency care and isn’t able to see their usual dental practitioner.

While records are made in real-time, dental professionals under pressure can legitimately revisit their notes whenever they like. In addition, digital audio can be transcribed for a complete text that can be appended to any written or digital record too.

Audio recording can really help improve patient engagement as records can be easily shared. Patients always have the right to access their notes and may request a copy of their written, photographic, x-ray and audio records. Sharing in this way allows patients to review and fully consider their options when deciding and consenting to a course of treatment, engaging their wider carer and support network if appropriate. This gives them a greater involvement and understanding of their care which can only serve to improve the entire dental experience. 

Dentists should remember that generic recording software may not be suitable when deployed in the dental field. It needs to ensure you remain compliant with the requirements of the Information Commissioner’s Office (5), the General Data Protection Regulation (GDPR) (6) and the NHS Data Security and Protection Toolkit (7) for handling highly sensitive personal data.

It must be remembered too that patients need to give their consent for any audio recording from the outset. This can be simplified when the software handles consent neatly for you, and by including audio in the practice privacy policy signed by your patients.

Another advantage of digital notes is that they can never be lost, and the right person can access the record at the right time. As part of the patient’s record, dentists need to archive the recordings for a minimum of 11 years and store them securely. The files need to be encrypted too. You need to ensure your audio recording software providers can manage the necessary storage, security and privacy issues for you if choosing to explore this route.

One such dental-specific audio recording software provider is Dental Audio Notes (DAN). Members of the Association for Dental Implantology (ADI) can currently benefit from a 20% discount on a monthly subscription to DAN. Becoming a member offers a range of benefits that can greatly enhance a dental professional's career and the quality of care they provide to their patients. On top of providing an excellent networking community, numerous events and conferences and access to a wide range of educational resources, the ADI also collaborates with industry partners to offer exclusive member-only discounts which can significantly reduce practice overheads and boost the profitability of member dentists.

Dental professionals who have access to more and better quality information, in regard to their patients’ records, will enjoy the benefits of improving both patient care (8) and the running of their practice.

View other News