HEALTH RECORDS
Introduction
Dental practitioners create health records that include dental, medical and medication information that serve the best interests of patients and contribute to the safety and continuity of their dental care.
Maidstone Dental’s Health Records Policy
Dental practitioners have a professional and legal responsibility to create, maintain, retain, transfer, dispose of, correct, provide access, store securely, and safeguard against loss or damage of health records in accordance with relevant standards, guidelines and legislation, including:
Maidstone’s Health Records Process
The practice has elected to use Exact Dental Software, to ensure that an accurate and integrated patient health record is documented and maintained. Patient health records include dental, medical and medications information.
This system ensures patient health records are readily available to dental practitioners and dental staff at the point of care (in the room where the patient is being treated). This system also allows for systematic review of the contents of a patient’s health record as an evidence-base when required.
Collecting Information
Maidstone Dental has developed and implemented processes for collecting information about pre-existing healthcare associated infections, communicable disease status, known allergies and adverse drug reactions upon presentation of a patient for care. One of the mechanisms for acquiring this information is the collection and recording of a comprehensive medical/medication history to ensure minimisation of risk and adverse reactions/events.
A medical and medication history is required to be obtained for new patients prior to the provision of care and is updated at regular intervals of no more than 12 months.
Principal Dentist requires dental practitioners to routinely (at each appointment) ask patients for updates to their medical/medication history.
The medical and medication histories are to include at least three patient identifiers, and where appropriate:
PATIENT RIGHTS
Introduction
Within Australia, the Australian Charter of Healthcare Rights (ACHR) applies to the entire healthcare system, and it allows patients, consumers, families, carers and healthcare providers to have a common understanding of the rights of people receiving healthcare. The rights included in the ACHR relate to access, safety, respect, communication, participation, privacy and comment.
Maidstone Dental’s Patient Rights Policy
Maidstone Dental has developed the following practice specific charter of patient rights that is consistent with the Australian Charter of Healthcare Rights.
In accordance with the Privacy law, Commonwealth Privacy Act 1988, the Dental Board of Australia’s Code of Conduct for Registered Health Practitioners, the Office of the Australian Information Commissioner- Australian Privacy Principles and a patient can expect their personal health and other information will be collected, used, disclosed and stored in accordance with relevant laws about privacy, and this information will remain confidential unless the law allows disclosure or the patient directs us to release the information.
Maidstone Dental’s Charter of Patient Rights
Appointments
Maidstone Dental aims to provide patients with appointments to meet their treatment needs. It is requested patients make an agreed appointment time and date to assist the scheduling process, notifying the practice where this appointment cannot be met. To assist you in providing us with this information we contact patients by:
The cancellation policy of Maidstone Dental; 24 hours’ notice for cancellation of an appointment. Should the patient cancel without the required notice period, it is at the Principal Dentist’s discretion as to whether a cancellation fee is to be charged, and if so, what this amount may be.
In the event we are unable to accommodate a patient’s request for an appointment at a specific time/date, consultation with the treating dental practitioner will be sought.
Safety
All patients are required to complete a full medical and medication history as accurately and completely as possible, to allow practitioners and staff to identify any circumstances that may increase the risks associated with dental care.
In the unlikely occurrence of an adverse event, dental practitioners at Maidstone Dental have a responsibility to be open and honest in communications with the patient involved, and families or carers if applicable.
It is the responsibility of the registered dental practitioner, in accordance with the Dental Board of Australia’s Code of Conduct for Registered Health Practitioners, to explain to the patient what happened and why, as well as offering support and advice with regard to how the situation can best be resolved or managed.
Open Disclosure
Upon recognising the occurrence of an adverse event, the dental practitioner will follow our Open Disclosure Process, which aligns with the Australian Commission on Safety and Quality in Healthcare’s Open Disclosure Framework, as outlined below:
Sufficient detail is to be recorded in patient records to reflect the information provided to the patient about the incident, associated risks and likely consequences. The dental practitioner will notify the occurrence of the adverse event to their professional indemnity insurer, consistent with the clauses of their policy.
Respect
Maidstone Dental values all patients as a unique person and hope that at all times we can provide dental treatment in a manner that is respectful of their culture, beliefs, values and personal characteristics. Patients are asked to reciprocate this respect by being mindful of all staff and other patients.
Communication and decision making
Maidstone Dental respects the patient’s right to receive adequate information to make informed decisions regarding their health and healthcare. Consequently, all staff should continually demonstrate a commitment to providing patients with accessible and understandable information about their treatment and treatment options, including costs, proposed medications and risks involved. We do expect patients to actively participate in decisions and choices about their treatment and dental needs, involving family or carers where required.
This should also include maintaining suitable evidence that patients are fully informed about their proposed treatment and have been a partner in the development of their treatment plan. Such evidence will be monitored through the practices records monitoring and review processes.
Informed Consent Process
The initial examination of a patient shall be considered ‘implied consent’ to that procedure based on the booking of an appointment, attendance, and the patient allowing the physical examination to occur. Any subsequent treatment shall require the patient to make an informed decision and consent to the treatment either verbally or in writing depending on the procedure and associated risks.
The dental practitioner who is to perform the treatment is responsible for the following informed consent process in line with the Dental Board of Australia’s Code of Conduct for Registered Health Practitioners.
A patient will be:
Dental practitioners are required to provide relevant documentation to the patient about the proposed treatment. The practice also requires dental practitioners to use their clinical judgement to determine where written consent is required from the patient and/or carer.
Dental practitioners shall take into account additional considerations regarding guardianship arrangements for consent matters when dealing with vulnerable patients.
Sufficient detail is to be recorded in patient records to reflect the information provided to the patient associated with their treatment options and the treatment plan, which is ultimately agreed upon.
Informed consent documentation
All informed consent documentation used is reviewed at regular intervals and any updates to these documents are designed to improve patient understanding and the quality of care provided.
Privacy
In accordance with the privacy law, Commonwealth Privacy Act 1988, the Dental Board of Australia’s Code of Conduct for Registered Health Practitioners, the Office of the Australian Information Commissioner- Australian Privacy Principles. Patient can expect their personal health and other information will be collected, used, disclosed and stored in accordance with relevant laws about privacy, and this information will remain confidential unless the law allows disclosure or the patient directs us to release the information.
The Privacy Policy of Maidstone Dental consists of the following: