My Journey to Better Dental Clinical Notes
This post was originally published at https://ouch.ai/blog/my-journey-to-better-dental-clinical-notes
Key Points
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Dental clinical notes are crucial for patient care, legal protection, and meeting UK CQC guidelines.
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Older dentists like me struggled with note-taking due to minimal training, while younger dentists use templates that often lack updates.
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I created Ouch Smart Notes, a digital tool that ensures comprehensive and accurate notes reflecting actual dental appointments.
Introduction to Dental Clinical Notes
As a UK dentist with nearly 30 years of experience, I've witnessed the evolution of dental clinical notes from minimalistic entries to detailed records crucial for patient care and CQC compliance. In this post, I'll share my journey, what drove me to creating Ouch Smart Notes and how it has revolutionised my note-taking process.
Challenges in Note-Taking
Traditional dental clinical notes often lacked the detail required by today's standards, leading to potential legal risks and hindering continuity of care. Younger dentists are generally better than my generation in some respects but they tend to cut and paste preformed emplates. However these can be generic and not updated, making it difficult to understand what actually happened during an appointment.
I am the first to admit that my notes over the years have been a weak spot for me. On occasion, I have relied on my longstanding knowledge of my patients and my relationship with them to avoid running into problems with my note taking.
My Solution: Ouch Smart Notes
So, I decided to do something about it. I created Ouch Smart Notes, a digital note-taking system designed for dentists. In building it I have leveraged because I was fed up with the trade-off between compliance and care. It’s a digital tool that lets me document everything in real time—think of it like my trusty sidekick in the surgery. During and after any dental appointment I can log the patient’s history, what I found on the exam, the treatment I planned, even the exact shade of composite I picked, and those specific pieces of advice I gave that patient, all without breaking a sweat. It’s not just about meeting CQC rules (though it does that too); it’s about making sure I’ve got a record I can trust, one that’s detailed enough to guide me and clear enough for anyone picking up my patient’s file later.
Detailed Analysis and Insights
And of course regulation isn't going anywhere. Dental clinical notes are the backbone of effective patient care and practice management in the UK, governed by guidelines from the Care Quality Commission (CQC) (CQC guidelines for dentists). They ensure continuity of care, legal protection in disputes, quality assurance through auditing, and better patient communication. According to CQC standards (Dental mythbuster 8: Dental care records), notes should include identification data, medical history, dental history, clinical and radiographic examinations, diagnosis, treatment plans, consent, and progress notes. The American Dental Association emphasizes that "if it's not written down, it didn't happen," underscoring notes' role in liability claims (What and How to Write, or Change, in the Dental Record | American Dental Association), which is particularly relevant in the UK, where CQC inspections assess record-keeping (CQC Dental Inspection Checklist | Radar Healthcare).
With nearly 30 years in practice, I recall when notes were minimal, often just a few words like "MO AR UR4" (MO amalgam restoration UR4). This approach, common in the past, no longer meets current standards. Attempting to recall details at day's end was error-prone, especially after busy schedules. This experience aligns with the evolution noted in dental literature, where record-keeping has become more detailed due to increased litigation and regulatory scrutiny (Record keeping for best practice - Dental Nursing).
Younger dentists, trained in a more regulated environment, often use pre-set templates to comply with CQC expectations. However, these templates can be filled out generically and become 'box-ticking;'. This lack of updates can lead to outdated information, complicating care continuity and auditing, as noted in CQC inspection reports (All inspections: Dental Practice - Care Quality Commission).
Ouch AI Smart Notes uses cutting edge voice recognition and AI for accuracy and efficiency to ensure the notes meet CQC requirements while reflecting actual appointments, with features like customisable templates, real-time note-taking, integration with patient records, search and retrieval for auditing, and security compliance under GDPR.
I believe that the principle reason for taking notes is to make patient care as good as possible. For me, the magic is in how it keeps things personal. I’m not just dumping data—I’m writing the story of what happened in that appointment, step by step. It’s comprehensive, sure, but it’s also mine, tailored to how I work and what my patients need. And yeah, it covers my back legally, but that’s a bonus, not the point. The point is giving my patients the best, most thoughtful care I can muster.
Implementing Ouch Smart Notes has transformed my practice, ensuring my notes are both regulatory-compliant and patient-specific, reducing legal risks and enhancing auditing processes by offering searchable, structured data. The system's integration with existing records streamlines workflows, a benefit noted in dental management literature (CQC - DentalNursing). For other dentists, adopting Smart Notes could improve note-taking efficiency and accuracy, especially given the increasing focus on documentation in CQC inspections (Dental mythbuster 17: Audit and improvement in primary dental services - Care Quality Commission).
A surprising insight for me is that using Smart Notes has made me transform from having the worse notes in my practice to the best; a fact noticed by the inspector at our recent CQC inspection!
Have you faced challenges with dental clinical notes in your practice?
How do you ensure your notes are helping you deliver world class care AND meet CQC standards?