Accurate Clinical Records Have Increased Staff Responsibility During Covid-19

clinical correspondence Aug 13, 2020

Now, more than ever, it is crucial to ensure you are keeping complete, effective, and accurate patient records. 

Not only is it your responsibility to ensure that the wellbeing and safety of your patients is being met, but it is also important to remember that as a community we want to do what is best for the welfare of all our patients to the very best of our abilities.

While it is becoming more and more difficult to provide optimal patient care within the usual time constraints as well as meet and exceed both existing and new cumulative requirements.

CDC Covid19 mandates in the Dental community 

As we are discovering with the newly added safety processes and procedures added to combat Covid-19, there is ever more responsibility resulting in even more effort going into the daily functionality of the care in which we provide. 

The necessity to learn about all the new processes and procedures in such a short period of time has overloaded the capacity of most dental teams providing care.  As a result, it is now much harder to keep up with our daily activities and to continue to provide the high-quality standard of care that has always been of utmost importance.

Accountability, Responsibility, and Liability… 

The role of all dental professionals involved in patient care has always included the responsibility to provide care that meets or exceeds a specific standard and Covid-19 is not going to make it any easier.

Anyone working in the medical and dental community should be held accountable by these set standards. So, why, and how are some practices providing and achieving a higher level of care than others?

The word accountability in and of itself implies the individual has the “ability” by definition and can, therefore, be held to account.  The problem is the responsibility given to our dental professionals is contingent upon a tacit assumption that the required criterion is in fact being met. Although it is often implied as opposed to being measurably standardized, all the legal and moral implications still apply.

Ability is contingent on capability.

If the doctor is trying to hold staff accountable and responsible for something that is often not standardized, or consistent, tangible results will be a matter of luck, and no one is lucky all the time.

Certainly, there is a standard, but it will vary from practice to practice, doctor to staff member, and even person to person. It is up to the practice owner to assess his or her staff expectations and apply appropriate training as they see fit.  Again, these varying methodologies are generally very fuzzy in the way in which they are approached.

Often, it is assumed some staff members are not truly capable, and therefore those individuals are not held accountable.  Liability will always fall back on the practice owner, which in and of itself may seem to be a contradiction to the meaning of “accountability” of all dental professionals.

Uphold a high-quality standard of care

 Standardizing your practice to ensure that everyone is on the same page is imperative. However, it can be difficult to achieve for several reasons. We will discuss two main issues here in this article.


Staff often reports they do not have enough time to complete records properly. More often the problem is not lack of time, but rather due diligence.  It’s not necessarily negligence on the part of the staff member. What may seem like sloppy work on the surface is often caused by a lack of knowledge about the correct process in which they should follow. Your staff is spending more time on activities of lower value, which can negatively impact time constraints.

Loose regulation/ policies…

Staff often forgets steps and is relying on drafting open-ended statements that do not follow a consistent protocol.  Dental professionals’ educational backgrounds can come from any number of sources. This vast amount of personal experience levels creates variables in work performance and documentation techniques.  Once new staff arrives to join your team, they may or may not adopt your practice ideals unless you provide specific reasons for your philosophies. Without your input and guidance, they will likely end up “doing their own thing”.

Holding all dental professionals equally accountable is important. That sounds great, but how do we realistically achieve this when we have less time and are dependent on the various skill sets of the team members?

Success is having knowledge

Not having a clear, consistent, and required process or policy in your practice, leaves room for staff members to fall short of your practice ideology.  For your team to uphold standards that meet your core practice philosophies and professional level of care, they need to be very clear about your requirements so they can achieve the desired results.

Leaving decision making up to the staff on the fly will continue to foster inconsistency throughout your practice.  If you are facing a myriad of skill sets within your team, the simplest thing you can do is to create a requirement or policy that allows everyone to follow the same working criteria.  Having a well-defined process in place creates equality of outcome and consistency in your practice.

Tangible results will align with exceptional standards

Create a simple protocol that breaks down all processes in an aggregate fashion.  Examples include lists, forms, how-to guides.   Creating a formula or standardized template for each procedure and process will provide clear steps that any member of the team can follow. Following a checklist or filling in a template creates a systematic process and is much easier for people than relying on memory.  This methodology will help them follow the same form and function of proper record keeping. 

PANDA Perio has this type of record capability built-in enabling everyone using the system to see a complete map of what needs to be achieved.

Learning to do it right the first time will seem like more work in the beginning but ultimately its effectiveness creates a safety net that everyone can use to eliminate confusion and inconsistency.

The process of breaking down each step will also aid in the ongoing training process by default and naturally, both you and your team will reap the benefits long term as you achieve accountability, and reduce the risk of liability to your practice.

To save you even more time – PANDA Perio is already set up and ready to be used in a systematic way so that you can achieve that consistency across your entire practice in one easy to use program created by Periodontist for Periodontists.  

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