We know that as an industry the quality of the records we write could be better, as documented in several papers over the years. Usually at the end of the appointment a dentist will have no more than 3 or 4 minutes to write the notes. It is common practice for dentists to write as much information as their fingers can type during this time period.
We propose that notes are written in a different way. The dentist or nurse work their way through the Gabby template as the appointment progresses. Thus notes are contemporaneous, and dentistry becomes being about the team rather than the individual.
Andrew Walker, a Associate dentolegal adviser at Dental Protection wrote an article for Riskwise connect (June 2018), stating that a simple and effective way of improving the note quality is to train "your dental nurses to help in the process. With some training, and practice, dental nurses can be recording details of the conversations you are having with patients."
Both Len D'Cruz and Raj Rattan MBE have stated the same concept in the BDJ April 2018 (BDJ volume 224, No8, April 27 2018). In it they say " a dental nurse, sufficiently trained at distilling the dialogue that takes place between the practitioner and the patient, can record events and discussions in real time."
14.8% of all matters heard at GDC hearings in 2017 involve allegations or charges of poor patient record keeping. This is the second largest subgroup where the largest was poor treatment amounting to 21%. Similar figures were also seen in the preceeding years.
The template offering for the first release of Gabby is the Adult Examination, and is designed so that the nurse can aid the dentist by completing certain text fields, leaving the dentist to complete the rest. Working in this way allows a more detailed note written in less time, thus capturing pertinent information which the dentist or nurse might otherwise miss. We wanted to move away from the traditional layout of dental notes but at the same time ensure that the information requested remains useful and salient to both dentist and patient.
Team work is key. Team work is simplicity.
Further templates will be added and the product will evolve based on your requirements. Our users are our top priority.
Gabby has been designed to keep a record of not only how the notes are written, but also offer a statistical analysis based on these findings.
The audit feature reports on the completeness of each field for all notes created in the requested date range or latest set of templates.
Audits also monitor in accordance with FGDP guidelines, which all dental practitioners should aspire to. The more we align ourselves with this level the greater the detail placed in the notes and as a result the greater the level of defence when things don't go as planned.