NHS England has introduced new standard operating procedures (SOPs) in an attempt to streamline record keeping for dental practices.
The changes are designed to prevent dentists having to repeat ‘common steps’ for each appointment, which are placing additional time constraints on the clinician while at the same time making it hard to find the relevant details for each appointment.
The British Dental Association welcomed the ‘common sense’ approach, while medical indemnity firms described the change as a ‘landmark moment’
NHS England announced the changes on 3 August in an update on concise record keeping, having trailed the policy last year.
It has published example SOPs on routine, non-surgical dental extraction, orthograde (first time) root canal treatment, dental crown or indirect onlay preparation and fit, and an anterior composite restoration, as well as examples of clinical records with or without standard operating protocols.
On the update, NHS England said: ‘We recognise that clinical teams will repeat common steps whilst treating patients. Writing these steps out in full each time in the clinical notes not only places an additional time constraint on the clinician but also makes the details unique to the appointment contained within the notes harder to find. Therefore, the usage of SOPs is proposed as a way of streamlining record keeping.’
It added that the list of example SOPs is not exhaustive, advising practices to develop their own protocols, and that ‘a small amount of additional detail in the clinical records will still be required’ – for example, the amount of local anaesthetic used, as this will vary.
Len D’Cruz, head of BDA Indemnity, said: ‘A common complaint from dentists is the sheer amount of time it takes to write up their clinical records after an appointment. The GDC requires these to be written contemporaneously, but many clinicians struggle to do this while working against the clock.’
He added that while templates have become more common, they can become a ‘source of problems’ when they come pre-populated, and don’t reflect what happened in an appointment.
Dr d’Cruz said: ‘Copious notes do not necessarily mean more accurate notes, and a propensity to repetitiously detail treatment in the mistaken belief that it will protect dentists has led us to where we are.
‘The use of SOPs offers a chance to take the edge off these problems across both NHS and private practice. They can also act a checklist for clinicians which will help provide consistent and quality care to patients.’
Professor Raj Rattan, global adviser at Dental Protection, said: ‘This landmark guidance from NHS England has the potential to become a turning point in how dental records are created, helping the profession move away from defensive documentation and towards records that are proportionate, meaningful and centred on supporting high-quality patient care, while also freeing up a significant amount of time for dentists.
‘If adopted widely, these protocols could help free up thousands of clinical hours across the dental profession every year. At a time when dentistry is facing significant workforce, access and capacity pressures, any measure that helps clinicians reclaim valuable time for patient care deserves serious attention.’