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  • 1. Medico-legal in orthodontics Advertising orthodontic products and techniques to the public According to BOS advice sheets the advertisements which are often limited and exaggerated is unacceptable and unethical. It should follow the GDC guidelines. GUIDANCE ON WRITING PRACTICE LEAFLETS The Advertising Standards Authority requires all advertisements to be Legal, Decent, Honest and Truthful. Orthodontist duty of care This involve 1. Ethical responsibility  protect the life and health of patients  provide good dental care to acceptable standards  respect the autonomy of patients and their right to exercise control of treatment  in addition to the GDC standard 1. Continuing care  The treatment plan at all times is realistic in terms of the patient’s ability to comply, the time frame is reasonable, and the appliances are comfortable and sufficiently robust. If treatment has gone beyond the anticipated duration, the patient must be made fully aware of why and what the likely new timescale will be.  The removable/functional appliance fitted is user-friendly and that the design is the most appropriate.  Fixed appliance breakages are not due to archwire design faults or inappropriate bracket position and that the correct bonding procedure has been used.
  • 2.  Accessory appliances such as headgear or elastics are correctly prescribed; where there are difficulties, alternatives should be suggested and good instructions given. 2. Emergency care 3. Care of all member of the public
  • 3. Management of patient compliance  Cooperation is collaboration or teamwork  Compliance can be defined as obedience and requires a patient to follow an orthodontist’s instructions.  Record keeping is particularly important particularly in cases of non- compliance or nonattendance.  Parents of patients under 16 yeas of age should be involved at every level although where there is difference of opinion it is essential that Fraser competence* is understood. Compliance information delivery methods 1. The effective communication of responsibilities to the patient and parent is an essential part of obtaining informed consent 2. It is necessary to ensure that the message has been properly understood. 3. Explanations do not necessarily have to be provided by the orthodontist. It can be given by an orthodontic nurse or auxiliary. 4. Visual aids are useful and written leaflets should be given as take-away back-up information. The orthodontic patient compliance can be classified into: 1. Passive acceptance – wearing fixed appliances. 2. Exercise of restraint - patients will be asked to  Avoid certain foods and drinks,  Not abuse the appliance  Desist from habits such as biting on pens or sucking thumbs. 3. Active participation - where we ask patients to do things. These include  Maintaining good oral hygiene,  Using fluoride supplements,  Keeping appliances clean and in good order.
  • 4.  Wearing all sorts of removable appliances and adjuncts such as elastic bands  Keeping appointments,  Reporting problems when they arise, * Fraser competence, previously called Gillick , is a term originating in England and is used in medical law to decide whether a child (16 years or younger) is able to consent to his or her own medical treatment, without the need for parental permission or knowledge, if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed It is based on a decision of the House of Lords by Lord Scarman in the case Fraser v West Norfolk and Wisbech Area Health Authority [1985]. Non-compliance categories 1. Poor oral hygiene and diet control  Every attempt should be made to discuss the problem openly with the patient/parent.  The efforts made to modify patient behaviour should be clearly recorded in the clinical notes.  The issue of premature discontinuation should be discussed with the patient with adequate forewarning and any warnings recorded in the notes. 2. Poor wear of appliances and continued breakages  The orthodontist should be able to demonstrate that efforts have been made to eliminate the possibility that the breakages or poor wear might be due to clinical rather than patient related problems  Discontinuation of treatment can be considered.
  • 5.  A careful, clear written record should always be kept of any action taken or recommendation made. The orthodontist should inform the referring dentist and, when appropriate, notify either the Primary Care Trust or Health Board. 3. Poor attendance  It is important that every attempt to contact the patient is made.  If the practice operates a policy of charging for failed appointments, it is essential that this is made clear in any written information provided to all patients at the start of treatment and explanations that these charges are permissible within NHS regulations.  The making of further appointments should not be conditional on prior payment or the settlement of non-attendance charges. The child’s treatment should continue while debt recovery measures are in progress.  Continued failure to attend would suggest that the patient has effectively withdrawn consent for the continuance of care. In these circumstances, efforts should be made to inform the patient that wearing an unsupervised appliance carries risks for the dentition.  According to the NHS (GDS) regulations on discontinuation of treatment: A. When both parties agree that treatment should cease, it is not necessary to inform the Primary Care Trust or Health Board. B. Where the practitioner wishes to terminate treatment but the patient wishes to continue, the practitioner should apply to the PCT/HB. The PCT/HB may wish to investigate the matter by contacting either the practitioner or the patient or both. C. In respect of non-payment of money owed, whether for NHS charges or for charges for broken NHS appointments, a dentist or orthodontist may decline to continue treatment until any charge payable has been received.
  • 6. The use and storage of digital images At present it is difficult to provide clear guidelines concerning the use and storage of digital images, because advice differs between institutions, particularly NHS Trusts. Do I need to get consent for photography?  Permission should always be sought from patients before photographs are taken.  When taking an image of a patient, it must be explained to them why the image is being taken, the intended use and the arrangements for storage.  The DoH model consent policy (http://www.doh.gov.uk/) states that A. express consent for photographs is not required where there is no prospect of the patient being recognised B. Where it may be possible to identify an individual, written consent is required. C. Written consent is also essential for publication of any image. Photographic levels of consent: 1. for medical record use only 2. for medical record and teaching use 3. for one specific purpose e.g. a publication. What is the Data Protection Act?  The Data Protection Act (1998) allows individuals to find out what information is held about them, which will include any digital images.  The data controller must take reasonable steps to guarantee that the data are safe from unauthorised access, disclosure, tampering or loss.
  • 7.  This will include installing security arrangements such as password protection, regular backups and ensuring that all individuals who have access to the images are instructed about the need for confidentiality What about dental practice and the Data Protection Act? All dentists in general and specialist practice should be registered with the Information Commissioner, even if their practice is not computerised. What about hospital and community departments?  In most Trusts, clinicians will already be covered by the Trust/University data registration, provided they comply with the local rules of the Trust.  Trusts treat the storage of data extremely seriously and some now state that data should not be stored on any portable devices unless it is within an encrypted folder.  In some Trusts though, employees, including trainees who copy and store images for their own purposes, may be considered independent data controllers and will be required to register with the ICO. Who owns the copyright? Anyone who takes a digital image is the owner of that image and therefore owns the rights to it. Organisations, such as NHS trusts, might insist on owning the copyright of their patients’ medical illustrations.
  • 8. How secure are digital images?  There are several methods of protecting the authenticity of digital images.  These falls into two broad groups: watermarking and digital signature. The former embeds a pattern within the image that cannot be seen by the eye. Any alteration of the image in the form of cropping or rotating can therefore be detected. Digital signatures work in a similar way, but the information is attached to the image in a user-defined part of the file or an independent file Summary 1. Seek permission prior to taking digital images. 2. Obtain consent in cases in which the patient may be recognised from the image and record this using an appropriate BOS, Trust or practice consent form. 3. Record in the notes that digital images have been taken. 4. Ensure patients understand why images are being taken, how they are to be stored and used, especially if they are to be published or placed on a website. 5. Comply with the Data Protection Act – if you work in a Trust, seek advice from your local Data Protection Officer. If you work in practice, check that your current registration with the Information Commissioner’s Office covers digital photography. 6. Make appropriate secure arrangements for storage of images. 7. Ensure the original unaltered image is stored in an uncompressed format on a secure server.
  • 9. BOS Advice Sheet On complaints Causes of allegation in Orthodontics a. Lack of informed consent, b. Poor record-keeping, c. making misleading statements to patients regarding the need for and efficacy of the planned treatment, d. Treatment for TMD, e. carrying out ‘experimental’ treatments without properly informing the patients of alternatives, f. Advertising, g. Fraud claiming In order to prove negligence a patient must prove  a legal duty of care  a breach of that duty  resultant loss or damage Ways of complaint A. NHS dental treatment  If a patient receives treatment within the NHS a complaint can be dealt with by the NHS complaints process.  If a patient is unhappy about the way a complaint has been dealt with under the NHS complaints procedure in England and Wales, they can contact the Care Quality commission. B. Private dental treatment
  • 10.  if a patient has a complaint about private dental treatment which has not been resolved to their satisfaction using the practice’s own complaints process  They can contact the dental complaints Service, set up by the GDC. This service seeks to provide a mediation service and they have an on-line system to help patients write a letter of complaint to their dentist/orthodontist. This is an ‘independent’ dental complaints service. There are three stages of the complaints procedures: - Stage 1 – The Case Worker: 1. Case workers decide whether an allegation raises an issue the GDC can deal with and whether the information provided appears to raise a question that needs to be looked into. 2. If the answer to these questions appears to be ‘yes’, the matter is referred to the investigating committee (IC). 3. No decision is made at this stage about whether an allegation is true. Stage 2 – The Investigating Committee : 1. Panel is made up of 5 members: 2 dentists, 2 lay and 1 DCP . 2. The investigating committee considers the allegation, any comments from the dental professional, and any further comments from the person who made the allegation. 3. All parties receive a complete copy of the paperwork. 4. The committee then decides whether to refer the allegation to a practice committee for a full public inquiry.
  • 11.  If the IC decides there should be an inquiry they can, if necessary, refer the dental professional to the interim Orders committee (iOc) to consider whether to impose conditions or interim suspension until the inquiry has been held.  If the IC decides not to refer a dental professional to the practice committee, they can send them a letter of advice or warning, or take no further action. Stage 3 – Practice Committees The practice committees are: 1. Professional conduct committee 2. Professional performance committee 3. Health committee  If allegations are proved, The Committee then decides whether the registrant is unfit to practise and what action they should take.  The committee can take a number of steps, including imposing conditions of practice, suspension and erasure. A dental professional has the right of appeal.
  • 12. Child Protection Guideline for Orthodontic Practitioners All members of the dental team (including orthodontic practitioners) have a responsibility to recognise and act if child abuse is suspected. Types of abuse 1. Physical Abuse - may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. 2. Sexual Abuse - involves forcing or enticing a child or young person to take part in sexual activities, whether or not the child is aware of what is happening. 3. Emotional Abuse - is the persistent emotional ill-treatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. 4. Neglect - is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in a serious impairment of the child’s health or development. Signs of Abuse Sexual Abuse  Being overly affectionate or knowledgeable in a sexual way inappropriate to the child’s age  Lack of trust or fear of someone they know  Become worried about outdoor clothing being removed  Extreme reactions, such as depression, suicide attempts.  Personality changes.  Regressing to younger behaviour patterns such as thumb sucking
  • 13.  One has to be very cautious as many of these symptoms occur when there is no sexual abuse present. Physical Abuse  Unexplained recurrent injuries or burns  Improbable excuses or refusal to explain injuries  Wearing clothes to cover injuries, even in hot weather  Bald patches on scalp  Fear of physical contact - shrinking back if touched  Fear of suspected abuser being contacted Emotional Abuse  Continual self-depreciation (‘I’m stupid, ugly, worthless, etc’)  Overreaction to mistakes  Extreme fear of any new situation  Neurotic behaviour (rocking, hair twisting, self-mutilation) • Neglect  Poor personal hygiene  Poor state of clothing  Untreated medical and dental problem Bullying Bullying is a particular form of abuse most often inflicted by a child’s peers. Either direct or indirect bulling such as social isolation.
  • 14. Boys tend to be more exposed to direct physical bullying than girls. When bullying is suspected by a treating orthodontist, it is important to acknowledge the concern with an accompanying parent, and seek reassurance that the issue has been raised with the school or other appropriate authority. Management of child abuse 1. Record your concerns as soon as possible begin by documenting all facts: what you saw, what was said, physical evidence e.g. ‘the mother said this’, ‘the bruise was here’ 2. Record details of any witness 3. The clinician has a duty to assess a child’s capacity to decide whether to consent to or refuse investigations as long as they are deemed mentally fit to do so. 4. The clinician has a duty to share information with those agencies with a statutory duty to investigate possible child abuse. 5. Regarding the consent for further investigation:  Child in Need – Parental consent required. Refusal may leave you thinking that the child is at risk, but NOT always  Child at Risk – Parental consent is NOT required. Informing parents of concerns and the referral is good practice
  • 15. Communication is the key to good Patient relations 1. Poor communication involves  non-attention,  miscommunication  No communication. 2. It considered as a major predisposing factor for patient complain. 3. According to BOS 2010-2011, 40% of the 108 more serious calls were precipitated by a breakdown in communications either during or after treatment. 4. Research consistently shows that over 60% of all patients’ complaints do not involve operator error but are made because their expectations of a good level of service have not been met.(Krause 2006) 5. Therefore in order to manage and reduce the risk of dissatisfied patients, good communication skills are an essential part of everyday practice, not only from the orthodontist but from all members of the orthodontic team. 6. The responsibility of the orthodontist regarding the communication with the patient involve discussing:  benefit of treatment  the necessity to treat  risks of treatment options  risks of no treatment  limitations and expectations  necessary cooperation
  • 16. Consent in orthodontics  Consent to treatment is essentially a process, not a signature. This process is the communication of key information to the patient about the proposed treatment and the patient’s response in terms of an informed decision whether or not to proceed Who can give consent?  Patients can only give consent if they are competent to make the decision.  Adults(above 18 years) and young people aged 16 or 17 are presumed to be competent to give consent for themselves  Patients fewer than 16 who understand fully what is involved in the proposed procedure can also give consent.  Legally a person with parental responsibility can give consent if the child refuses. This would generally be unwise in an orthodontic context as the success of treatment is very dependent on the co-operation of the child.  A competent child can in principle consent without the agreement of the parents, but as parental support is also a key factor in the success of treatment, every effort should be made to reach consensus.  Although an unaccompanied child may be competent to give consent, it is wise to encourage the child to involve the parents if at all possible, and to give the parents an opportunity to discuss the treatment with the clinician.  For a child under 16 who does not have sufficient understanding to give informed consent, consent is required from a person with parental responsibility.  In England and Wales, if the parents of a child are married to each other at the time of the birth, or if they have jointly adopted a child, then they both have parental responsibility. Parents do not lose parental responsibility if they divorce, and this applies to both the resident and the non-resident parent.
  • 17.  This is not automatically the case for unmarried parents. According to current law, a mother always has parental responsibility for her child. A father, however, has this responsibility only if he is married to the mother when the child is born or has acquired legal responsibility for his child through one of these three routes: A. . (from 1 December 2003) by jointly registering the birth of the child with the mother B. . by a parental responsibility agreement with the mother C. . by a parental responsibility order, made by a court  Living with the mother, even for a long time, does not give a father parental responsibility and if the parents are not married, parental responsibility does not always pass to the natural father if the mother dies.  When a child is adopted, the adoptive parents are the child’s legal parents and automatically acquire parental responsibility.  Foster parents rarely have parental responsibility.  A guardian appointed by a court will also acquire parental responsibility.  People looking after the child such as child-minders, grandparents or schoolteachers do not automatically have parental responsibility, but parents can authorise them to make medical decisions for the child. Many schools, for example, seek explicit agreement in advance from parents that teachers may consent to any treatment that becomes necessary whilst the children are in their care.  In the case of patients with mental incapacity, the parents can consent for a minor, but not for adults. In the latter instance the clinician has to make a judgement as to whether the treatment is in the patient’s best interests; the views of relatives should be taken into account but they cannot give consent. It is important not to underestimate the competence of patients with a degree of mental incapacity to give valid consent;
  • 18. Types of consents A. Consent to examination. Orthodontic examinations are commonly carried out on the basis of implied consent B. Consent to treatment. In seeking consent in orthodontics the following factors need to be addressed: 1. Patient commitment: in terms of  regular attendances  the possibility of time out from school or employment,  oral hygiene requirements,  dietary restrictions,  discomfort,  extractions,  appliances and post-treatment retention.  The need to continue regular visits to the family dentist 2. Benefits of treatment: in terms of  appearance,  occlusal function,  the TMJ  other areas (as appropriate to the case) 3. Limitations of treatment: Patients should be clear about what the treatment will and will not achieve, particularly if the treatment objectives are limited. 4. Risks of treatment: including  The possibility of relapse.  Decalcification  Gingivitis  Root resorption
  • 19. 5. Multidisciplinary treatments: The patient must be given sufficient information at the outset to be able to consent to both the orthodontic treatment and the associated procedure before either treatment is started. 6. Treatment options 7. Retention: Patients should be informed, before the start of treatment, that wearing retainers is generally considered an essential part of treatment. They should also be aware of the type of retainers to be used, the length of time they will need to wear them and the period of supervision provided. The nature of any charges associated with a patient’s long term retention requirements should be explained to them. 8. Photographs: The purpose and possible future use of the photographs must be clearly explained to the person, before their consent is sought to take the photograph 9. Reaffirming consent. Where there has been a lengthy delay between the initial consultation and the start of treatment (as for example when a patient has been on a treatment waiting list), the patient’s views or circumstances may have changed, or treatment techniques may have evolved. Reaffirmation of consent is needed. 10.Withdrawal of consent: Consent to treatment can be withdrawn at any time, even in the middle of a course of orthodontic treatment. If a patient indicates a wish to terminate treatment, advice should be given to the patient on any likely adverse consequences of a premature termination. If the patient continues to request termination, the operator is obliged to comply and must remove any fixed appliances. C. Consent to continuation of treatment. The fact that a patient continues to attend for treatment in the normal way can be regarded as implied consent for its continuation.
  • 20. D. Consent for a change of plan. The patient should be fully informed of the circumstances and continuation of consent confirmed. Written or Verbal Consent?  There is no legal requirement for consent to be written.  Written confirmation of consent may be thought to offer a more satisfactory defence in the case of subsequent litigation The GMC recommends that written consent is obtained in cases where: 1. The treatment or procedure is complex, or involves significant risks and/or side- effects 2. There may be significant consequences for the patient’s employment, social or personal life 3. The treatment is part of a research programme 4. Procedures in orthodontics where written consent is particularly desirable are joint treatments that involve surgery or complex restorative work. For other procedures clinicians will need to take account of local policy and the perceived needs of the case. The NHS Litigation Authority has recently issued an alert regarding changes to the law on informed consent. A recent decision by the House of Lords in the case of Chester–v- Afshar (2004) has had the effect of significantly extending clinicians’ liabilities in cases where less than full consent is obtained. Although the judgement of this case applies only to English courts as precedent, it will have significant effects generally. Miss Chester suffered repeated episodes of low back pain and an MRI scan revealed evidence of disc protrusions. Following injections and conservative treatment she was referred to Mr Afshar, a consultant neurosurgeon. He advised that three intervertebral discs should be
  • 21. removed surgically. Miss Chester gave consent to the operation, which then went ahead. Cauda equina syndrome (CES) is a well-recognised risk of such surgery and occurs in 1-2% of cases. Despite the patient’s operation being carried out extremely competently, this risk materialised and she ended up with CES. Miss Chester sued Mr Afshar claiming that he had failed to warn her of the potential risk.Because Mr Afshar had no evidence to the contrary, the court accepted Miss Chester’s allegation and liability was established. The surgeon argued that his failure to warn the patient was irrelevant to the outcome because Miss Chester could not state that, given appropriate warnings, she would not have proceeded with the operation. The guidance of the GDC remains the most appropriate, legally enforceable, framework within which to operate. The key features are: 1. Putting patients’ interests first and acting to protect them 2. Respecting patients’ dignity and choices 3. Protecting patients’ confidential information 4. Co-operating with other members of the dental team and other healthcare colleagues in the interests of the patients 5. Maintaining your professional knowledge and competence 6. Being trustworthy
  • 22. Second opinions Do patients have a right to a second opinion? Answer All patients have a right to second opinions at any stage during assessment, diagnosis,whilst in treatment or at the end of their orthodontic treatment. Second opinions can be provided a) Before treatment to confirm a diagnosis and treatment plan. b) D uring treatment to assess the progress of treatment and to allay any fears that the patient may have. c) After treatment to confirm that the outcome is consistent with good practice and to discuss any long term issues. Procedure for the practitioner who provided the first opinion When a patient requests a second opinion, a practitioner should: 1. Write to the patient acknowledging their wish. 2. Write to their general dental practitioner pointing out that the patient has asked for a second opinion. 3. Agree to send any appropriate records to the practitioner identified to provide the second opinion. Procedure for the practitioner providing the second opinion Once a second opinion has been given, the practitioner should: 1. Send a report to the patient. 2. Send a report to the referring practitioner. 3. Send a report to the current orthodontist 4. Suggest, if considered necessary, that if the patient’s continuing orthodontic care is to be provided by the first orthodontist then the treatment plan is either:  revised if necessary before treatment commences, or
  • 23.  re-evaluated if necessary during treatment, or  Arrangements are made for the patient to undergo the treatment with another orthodontist. 5. Return any records to the patient’s general dental practitioner or referring practitioner as appropriate.
  • 24. Waiting list management Where government and/or purchaser targets allow, waiting lists for orthodontic care can be managed using one of two methods: 1. New patient waiting lists A new patient is seen for a consultation when an opportunity for treatment exists. • This has the advantage of being able to offer immediate treatment to any patient who is eligible and willing to receive care. However, in this system, referred cases go to a waiting list without examination risking the late diagnosis of potentially harmful conditions not identified in the referral and the delayed delivery of growth dependant procedures. In addition, there may be a delayed decision as to whether the severity of the malocclusion merits NHS orthodontic treatment. 2. Treatment waiting lists This system offers a consultation soon after receipt of the referral and allows: • Reassurance if treatment is not, or not immediately, indicated and when coupled ith appropriate advice may fulfill the requirements of the 18 week wait from referral to treatment • Identification and immediate management of potentially harmful problems • Immediate referral to a more appropriate provider if required • Identification of those in greatest need of treatment • Explanation of the proposed treatment plan • Explanation of any further waiting time for treatment
  • 25. THE DUTIES AND RESPONSIBILITIES OF EXPERT WITNESSES Why are such expert witnesses necessary?  In cases of alleged negligence, as courts have no expert clinical knowledge themselves, there is a need to be able to objectively assess the skill of a clinician against what is reasonable clinical practice. For this reason the courts will hear expert evidence for the claimant and the defendant. The criteria of the report and Duty to the court 1. The report should indicate whether the defendant met an appropriate standard of care (taking all the circumstances into account) and if there was a failure to meet such a standard, did this failure cause the injury to the claimant, i.e. causation. 2. The expert is not being asked if he or she would have diagnosed/treated the patient in the same way, but to indicate if the diagnosis/treatment is reasonable. 3. If there is a range of approaches to a particular set of clinical circumstances, then this should be indicated in the report. 4. If any literature is quoted it should be that relevant at the time the alleged negligence took place. Woolf reforms  Changes in the Civil Procedure Rules, following recommendations by Lord Woolf when he was Master of the Rolls, were introduced on the 26th April 1999. These include: 1. Reducing the number of expert witnesses. 2. Increasing reliance on a single joint expert witness 3. Encouraging parties to an action to settle as early as possible to reduce the costs of litigation by allowing either side to make an offer to prevent the case reaching court.
  • 26. Orthodontic records collection and management Why are good clinical records important? 1. For effective and efficient orthodontic practice 2. important means of communication 3. For responding to complaints 4. For improving standards of patient care and Auditing What constitutes the clinical record? 1. Handwritten notes 2. Computerised records 3. Correspondence between health professionals 4. Correspondence from the patient (not relating to complaints) 5. Radiographs and other imaging records 6. Laboratory or radiography reports 7. Photographs, videos and other recordings 8. Orthodontic study models 9. Statements concerning custom-made devices provided under the Medical Devices 10.Regulations i.e. laboratory sheets 11.Consent forms 12.NHS forms Writing good clinical records Notes should include:
  • 27. 1. Reason for referral. 2. Patient’s presenting complaint. 3. History (dental, medical and social). 4. Details of the orthodontic examination. 5. Description of radiographic findings and the results of special tests. 6. Orthodontic diagnosis in clear, easily understood terms. 7. Record of the level of treatment need e.g. IOTN. 8. Treatment aims and options for treatment. 9. Treatment plan (it should be clear from the notes how you arrived at this plan). 10.Details of discussions with the patient and information given, including details of risks and benefits of particular treatments. 11.Details of any consent that the patient or guardian has given. 12.Details of treatment undertaken. 13.Details of any mishaps or complications. 14.Appropriate outcome records. Access to clinical records  Unless patients specify otherwise, there is usually no problem in sharing information with other health professionals involved in the patient’s current care. However, it may be a good idea to tell patients that you will do so.  Under the terms of the Data Protection Act (1998), any patient has a right to access or view their medical records within 40 days of a written request. Disclosure  It is your professional duty to respect the confidentiality of all information you hold on a patient. You may be asked to disclose a patient’s records to certain individuals orauthorities e.g. relatives and carers, social services, police,
  • 28. solicitors, the courts. Except inexceptional circumstances, always seek the patient’s consent to disclose any informationabout them to others. For consent to disclosure of records to be valid, the patient mustunderstand: to whom the information will be disclosed, what information will be disclosed,the purpose of disclosure, the significant foreseeable consequences and that relevant information cannot be withheld except in exceptional circumstances.  You should respect the wishes of a patient who has not given permission to disclosureunless this can be justified to be in the public interest. Altering clinical records  If a mistake is discovered, an additional note should be added as a correction. Notes should never be erased, overwritten or inked out.  Errors should be scored with a single line and the corrected entry written alongside, dated and signed. Retention of the dental records  Defence organisations however, recommend that ideally all recordsshould be retained indefinitely.  There is a conflicting demand between the destruction ofrecords, which is irreversible and the continued storage of records, which is expensive.  Record should be kept for 11 years for adults.For children 11 years or up to their 25th birthday, whichever is the longer. X-Ray films should be kept for 7 years.
  • 29. Orthodontic transfer cases To help in patient transfer these guidance notes are subdivided into three: 1. Transferring a patient  Finding a new orthodontist  The transfer method: When transferring a patient, sufficient information should be forwarded to the neworthodontist to enable treatment to continue with the minimum of disruption. A suggested minimum data set is outlined on the BOS Case Transfer Form and should include a set of duplicate records where appropriate. You should keep the original records until after the transfer has taken place.  Prior to the transfer: Try to ensure all the appliances are in good order and that the oral hygiene is as satisfactory as possible. It is advisable to take up to date records, such as study models and photographs, just prior to transfer to the new orthodontist. Both the patient and parents should be advised that the accepting orthodontist will have full authority to treat the case in a manner that they feel is best for the patient. 2. Accepting a transfer  Once you have received a referral letter and records consider the following:  If you are unable to accept the transfer, or following examination feel unable to do so, let the referring orthodontist know as soon as possible. If possible try to secure the services of another competent orthodontist in your area.  Following a review of the diagnostic data, inform the patient and/or parents of the procedures necessary to achieve a successful treatment outcome and particularly anyfee schedule where relevant, then the patient should be welcomed into the practice as quickly as possible.  Sometimes patients under treatment arrive without being referred. In such cases it is prudent to write to the original orthodontist to request the necessary transfer
  • 30. information, as outlined in the BOS Case Transfer Form, along with a set of duplicate records, in order to avoid unnecessary confusion.  It is advisable to get up to date records, such as study models and photographs, before continuing the orthodontic treatment.
  • 31. Orthodontic extractions risk management guidelines The purpose of this guideline is to minimise the chances of a mistake being made when the patient is referred for the extractions to be carried out. 1. A request should be made in writing. 2. It should include the name, address and date of birth of the patient, a brief outline of the proposed treatment, its timing, any relevant medical history and the extractions needed. 3. It is preferable to identify the extractions by at least two different methods. 4. The identification of erupted supplemental or supernumerary teeth poses particular problems. There is no generally accepted method of notation, which provides for unambiguous identification and a simple description in words is recommended e.g. "the more distal of the two upper left lateral incisors". 5. The teeth listed for extraction in the letter must be checked directly against the patient record, which should always be to hand when the letter is signed. 6. If as occasionally happens a dentist telephones the practice/ department needing to know urgently which teeth are to be removed, verbal instructions should be avoided wherever possible and the information sent out in a signed and dated extraction letter faxed to the practice. 7. If a fax is not possible, it is essential to speak directly to the dentist and not via a third party such as a dental nurse or receptionist. The information must be read out from the notes and not from a copy letter (which may contain uncorrected errors). The information should be repeated back for checking. A follow up extraction letter should always be sent to the practice for confirmation. 8. If the dentist carrying out the extractions questions the choice of teeth for removal, an offer should be made to see the patient again in order to confirm or modify the treatment plan before the extractions are performed.
  • 32. Breaches of Confidence Even though strict adherence to the principles of confidentiality should be observed at all times, there are some extreme cases where a breach of confidence can be justified. 1. Research and teaching 2. Audit Audit is an essential and mandatory part of clinical governance. However, where possible,patient consent should be obtained or data anonymised. 3. Court Order 4. Police Request The police are not automatically entitled to access to personal patient data unless they produce a court order. The clinician must satisfy him or herself that there is a definite public interest, justification and document it clearly in the patients’ notes. If in doubt, legal advice should be sought. 5. Risk of Harm/Public Interest Where there is risk of serious harm to an individual(s), for example, the spread of a serious disease or child abuse, a breach may be warranted. Each case should be assessed on its’ own merits and legal advice sought and the breach should be limited to the minimum necessary. 6. Healthcare It is permissible to liaise with other healthcare professionals involved in a patient’s care without explicit consent, but where possible it is advisable to ensure that the patient is content with the disclosure.