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Consent, records and communication - do you know the drill?

Good communication in dental practice is associated with more accurate diagnosis, improved health outcomes and less likelihood of complaints or litigation. Communication is a complex clinical skill that involves showing empathy, listening as well as sharing clinical information. 

Key messages 

  • Effective communication in dentistry involves a triage of skills – conveying clinical information, active listening and showing empathy. 
  • Explain, inform and obtain informed consent from your patients. This will help to retain your patients and improve your practice/business by effective word of mouth. 
  • When adverse events occur, good practice involves keeping honest communication with the patient, reviewing and rectifying what has occurred and recording the incident appropriately.

Dental Board Code of Conduct 

Working with patients or clients 

Summary of 3.3 Effective communication 

  • Listening to patients, asking and respecting their opinions and views 
  • Adjust your communication style according to patients’ health literacy
  • Encourage patients to talk about their condition and describe how they manage it 
  • Keep patients informed about the nature of treatment and give them opportunities to question and/or refuse treatment 
  • Discuss limitations, possible adverse and positive consequences of treatment options 
  • Ensure patients understand the information being conveyed to them 
  • Communicate any risks associated with treatment plans 
  • Respond to patients’ questions and keep them informed about their clinical progress 

Informed consent 

Summary of 3.5 Informed consent 

  • Make sure patients understand the information given to them before asking for their consent 
  • Obtain informed consent before undertaking any examination, investigation or treatment 
  • Advise any additional costs that may be involved before proceeding with a patient or client referral for investigation or treatment 
  • When working with patients whose capacity to give consent may be impaired or limited, obtain the consent from individuals with legal authority to act on behalf of the patient. 
  • Be mindful of additional informed consent that may be needed when prescribing or supplying product not approved or made in Australia 
  • Document consent appropriately, consider written consent for procedures that may carry serious injury or death. 

Fees and financial consent (continuation of 3.5) 

  • Provide patients with clear information about fees and charges before any treatment commences. 
  • Maintain a professional manner when discussing fees and the costs of all required services and agreements

Maintaining records 

Summary of 8.4 Health records 

  • Keep accurate, up to date, factual and legible records of clinical history, clinical findings and investigations, information given and medication. 
  • Ensure records are held secure and not subject to unauthorised access, either in paper or electronic format 
  • Show a respectful attitude towards patients and clients in the records. Avoid demeaning or derogatory language 
  • Ensure records facilitate the continuity of care 
  • Write records at the time of events or as soon as possible 
  • Acknowledge the right of patients to access their health records 
  • Facilitate the prompt transfer of health information when requested by patients or clients. 

Communication tips to build your practice 

  • Experience is key to grow your practice , and good communication is the key to retain your patients 
  • Always talk to your patients in a respectful manner
  • Educate your patients, give them the tools to make informed decisions 
  • Always explain, inform and obtain informed consent before any treatment commences. 
  • Consent should be discussed between yourself and the patient and appropriately recorded. 
  • Be upfront about charges and fees, audit trail can be requested.
  • When adverse, unplanned or unexpected results occur, it is recommended that you: 
  • Explain to the patient what has happened and the anticipated long- and short-term consequences 
  • Act immediately to rectify the problem, including referrals if appropriate 
  • Record the event fully, including diagnosis, explanations given, options for resolution and the resolution chosen by the patient 
  • Seek advice from MIPS as soon as possible. This is a membership condition. 

References 

Dental Board Code of conduct

When in doubt

Contact MIPS’ 24 hour Clinico-Legal Support.