Hannah Burrow explains the importance of recording the patient's clinical journey.
There are a number of risks and benefits which come with dental extractions. It is important that patients are made aware of each of these, and that they are presented with all relevant options, including that of no treatment. Importantly, clinicians should also be sure to make detailed notes of these conversations in the patient’s clinical records, demonstrating they have been able to provide informed consent prior to treatment. For protection from litigation, it is important that all relevant information has been recorded in the patient’s notes, with accuracy. This will ensure that the notes are GDC compliant.
Reasons for dental extractions
Where achievable, it is preferable that a patient should keep as many of their natural teeth as possible. In many cases restorative procedures and endodontics may be used to preserve the health of the tooth, preventing the need for extraction. However, in some situations where the tooth is not viable, it may be necessary to recommend the possibility of extraction. Clinicians should always discuss all of the possible treatment options with their patients, and the risks and benefits of each, to ensure that they are able to provide informed consent. They should also offer the option of no treatment, along with any consequences of this.
There are a number of reasons why dental extraction might be recommended. These may include severe caries, periodontal disease, tooth fracture, abscesses, crowding, or impacted wisdom teeth. When necessary, dental extractions are able to prevent damage to neighbouring teeth and create adequate space for effective orthodontic treatment. But extractions should only be carried out where appropriate, and with careful consideration.
What are the risks?
There are a number of risks which come with dental extractions, the most common of which is dry sockets. This occurs when the blood clot at the surgical site is dislodged and can be exacerbated by smoking, causing the patient significant pain. It is important to provide patients with all the advice they will need for recovery to avoid this complication, advising against rinsing and spitting out blood clots, and against smoking during recovery.
Some complications are linked to patients’ medical histories too, for example, increased risk of slow healing and wound infection have been linked with diabetes. Additionally, the surgical site itself can pose a unique challenge. Removal of wisdom teeth, for example, can present risks as they are located close to the alveolar nerve. Because of this, it can be beneficial to utilise diagnostic CBCT images to improve accuracy. Clinicians should be sure to tailor recommendations to each patient and provide them with information regarding the unique risks of their individual treatment.
The importance of clinical note-taking
For both the clinician’s safety, and that of the patient, it is important that patients are provided with all the information they need to both make an informed decision about their treatment path and to minimise the risk of complications. Individuals should be informed of any risks of dental extractions, as well as the benefits, and a record of these conversations should be kept in their clinical notes. This is important to protect the clinician should they come up against litigation, and to ensure that patients are provided with the highest standard of care.
With Kiroku, the digital note-taking platform, clinicians are able to record their clinical notes 60 per cent faster than without the technology. Kiroku prompts the user to include information relevant to each case, presenting a number of clickable options for the clinician to select. This means that note-taking is easy, and able to be completed during the appointment, keeping the notes as accurate and contemporaneous as possible. Plus, thanks to helpful prompts, clinicians can relax knowing that all relevant information has been included in the clinical notes.
By taking care to include conversations with patients in the clinical notes, it is made clear that the clinician has provided the patient with all the information they need to provide informed consent. When individuals are aware of the risks of treatment, they are able to adjust their expectations, and they raise any concerns they may have with their clinician prior to treatment. By having open discussions with patients, it becomes easy to create a treatment plan which is right for them, and offer appropriate recommendations for both treatment and recovery.
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