3.1 Introduction
Obtaining patient
consent is a moral principle, as well as a legal requirement.
Patient consent not only promotes
autonomy of decision making, but also reduces the likelihood of court action or
fines against the dental practice. The patient must be able to understand the
information and be mentally and physically able to make decisions for
themselves. Mercenary, business or financial interests must not be allowed to
interfere with the process of patient consent.
The importance of maintaining records
cannot be emphasised enough. Dental offices are required by UK law to maintain
updated patient records. Clear, organised and updated
dental records are necessary, in order to be able to provide the best dental
care. Records must contain all important information pertaining to medical
history, treatment options, costs and any refusal of permission on behalf of
the patient.
Patient confidentiality forms one
of the fundamental components of the patient/dental practice relationship.
Patients have a right for their information to be kept confidential. The
dentist must ensure that all staff members, including non-registered members,
are aware of the rules of confidentiality. Even if you need to share patient
data with a referring dentist, you must ensure that patient consent is obtained
first.
Dental teams must always work
together to promote the best interests of the patient. They should explain the
duties of the different team workers and define their roles. Staff members
should treat each other with respect and refrain from making disparaging and
derogatory remarks against other colleagues and workers. Your behaviour as a dental
assistant should reinforce confidence and trust in the dental practice and the
dental profession on the whole.
Assistants are the erstwhile link
between the administrative and clinical facets of a practice and they should
possess effective communication skills, including empathy and understanding.
Remember to demonstrate your best efforts, whilst maintaining a professional
and cordial relationship with patients.
3.2 Obtaining Valid Consent for
Treatment
The third principle of code of ethics involves obtaining valid consent
for dental treatment before it begins.
The dental team must ensure that the
patient's consent is obtained for every stage of the treatment process. As with
other medical procedures, dentistry is associated with its own set of mishaps
and emergencies. It is crucial to obtain valid patient consent, because dental
procedures performed without authorisation are vulnerable to court action and
can turn into a nightmare for the dentist. As a dental assistant, you must
keep track of obtaining patient consent for every patient and for every
irreversible and invasive procedure.
There are three main steps
involved in the informed consent process:-
*Effective communication
(explained in module 2)
*Provision of information
*Make an informed choice and give
informed consent
The member of the dental team who
takes patient consent must be fully aware of the risks and features of the
procedure and must be able to explain it. The dental assistant should be
trained to provide information in a clear and consistent format. Obtaining
consent is an ongoing process and not a one-off event.
The absence of obtaining informed
consent could lead to several negative repercussions, including court
proceedings against the dental practice. Regardless of whether you are the
first point of contact, do not assume that patient consent has been obtained by
someone else. Always double check, to ensure that patient consent has actually
been obtained in the correct manner. Obtaining patient consent can be described
as a moral principle, as well as a legal requirement.
Patient consent represents the
patient's right to participate in the dental treatment recommended to him. The
dental team member or the dentist must explain to the patient the conditions
that require treatment, the different options available and the costs involved.
The member must also explain the probable consequences that could arise if the
patient does not take the recommended treatment. This point must be explained
in a matter of fact manner and should not be misrepresented to promote the
business or financial interests of the clinic.
The information provided must be
in the best interests of the patient.
For example
If a general dentist suggests the
extraction of three lower teeth, he must explain the options available to the
patient.
These would include bridges,
implants, veneers and so on. The patient must be allowed to select the option
that works best for them. The general dentist must offer the options, even if
they are not offered at the clinic (in which case, he must refer the patient to
a specialist).
Activity 1
Estimated Time: 10 minutes
A research university approaches
you regarding the sharing of patient information for the purpose of research.
What factors would you consider
when explaining the request to the patient?
3.3 Types of Patient Consent
There are essentially three types
of patient consent:-
Implied consent: This is a more
passive process of communication, where the patient fully understands the
information provided. Implied consent is usually not documented in the records.
Verbal consent: Verbal consent is
usually adequate for diagnostic or standard procedures. When a patient gives
verbal consent, they do not sign any forms.
Written consent: Written consent
is mandatory for treatments involving sedation, anaesthesia, restorative
interventions, surgery, or administration of medications (such as antibiotics)
involving risks.
In a dental office, you will
often come across patients who are in great pain and simply want the pain to
stop as soon as possible. In such cases, it is best to administer a local
anaesthetic and allow the patient to make decisions in an alert and fully
conscious state. In the eyes of UK law, a written
consent is valid only if the patient has signed the form without impairment of
judgement. This statement includes the effect of alcohol and (medicinal) drugs.
If a patient refuses treatment
for any reason, this is called a “signed refusal”. A signed refusal implies
that all the options were explained, but that the patient has decided to refuse
treatment. A signed refusal is valid,
regardless of whether the dental team agrees with the patient or not. This
document absolves the dental practice of any medical responsibility in the
patient's treatment.
Written Consent Format
It is not enough to simply
summarise that the patient has been provided with full information. The
document must contain specific risks and side-effects and so on.
Some important components of the
written consent form include:-
*The proposed treatment plan and
costs.
*Prognosis, outcomes and benefits.
*Any risks, side-effects, or
complications associated with the treatment (such as reaction to an
antibiotic).
*Alternative treatments, options and
costs available.
*Likely consequences in the
absence of treatment.
The patient consent form should
be neatly typed and should contain the names of the patient, the dentist and
the witness, as well as the date. Ensure that the patient name is written clearly,
as signatures sometimes tend to be illegible. A clearly typed patient name will
also prevent confusion with other patient's with similar names.
The following questions need to
be considered carefully, before drafting a patient consent document:-
What information does a patient
(or the patient's caregiver) need to know and understand about the treatment in
question?
Is the patient capable of
understanding (competence and ability)? This is particularly relevant in the
cases of elderly and paediatric patients, patients who do not speak English, or
patients who suffer from mental health conditions. In cases where the patient is
accompanied by a caregiver, is the caregiver competent and authorised to
provide consent on behalf of the patient?
Has the consent been given
voluntarily?
There are some cases where
written consent may not be required:-
*In emergency cases, where there
is no directive advance from the patient
*Any medical treatment or
identification, etc to be carried out under court order.
In both cases listed above, the
dental team does not have to obtain written patient consent.
Obtaining Consent for Children
The primary responsibility for
giving consent for children or young adults (below the age of 18) rests with
the parents, guardians, or caregivers. Please note that the adult accompanying
the child to the dental office may not be authorised to provide legal consent
for medical procedures. This may include grandparents, step-parents, family
friends, aunties or uncles and so on. However, in certain cases, the
conventional procedure for obtaining consent for a child may be overlooked.
These circumstances are listed
below:-
*In emergency cases, evidence of
parental consent may be produced by other adults, such as grandparents or
step-parents
*A mature and competent child may
give consent for treatment, under certain circumstances.
*Telephone consent may be legally
admissible, under certain circumstances.
In cases of conflict of opinion
between parents and children, parental decision will override the children's
decisions. In emergencies (such as accidents and so on), the dentist has the
right to provide medical assistance without consent.
The dental assistant or team
member must take the following factors into consideration, when obtaining
patient consent:-
-Obtaining patient consent is not
a one-off process; it is an ongoing process until the treatment is complete.
For example, the patient may need to give consent for gum surgery, root canal
and implants, separately.
-Whilst carrying out dental
treatment, the consent must clearly specify the risks associated with that part
of the procedure.
-Consent information must be
tailored to suit the requirements of each patient.
-If you need to change the
treatment or costs, the changes must be explained to the patient and patient
consent for the changes must be carried out as recommended.
3.4 Protection and Maintenance of
Patient Information and Confidentiality
A patient's dental records must be
maintained from a professional, ethical and legal perspective.
The purpose of maintaining dental
records is to ensure that accurate information is available at every
consultation, in order to maintain continuity. The dental records also form the
basis of professional communication between dental professionals and members of
the dental team. Please note that according to the GDC, patient dental records
should be created and updated for every dental procedure and should be
maintained for a minimum of two years. This regulation applies to both NHS and
private dental office records.
Patient records should ideally
follow the four C's. These are explained below:-
Contemporaneous: The records
should be created and updated at the time of (or very close to the time of) the
discussion, consultation, diagnosis and treatment. Every update should be dated
and signed legibly.
Clarity: The records must be
clearly and carefully written, so that they can be interpreted and understood
by anyone who needs to consult them.
Concision: The records must be
concise, without missing out on essential information.
Complete: The records must be
complete and should contain the following information:-
*Medical history
*Dental charting
*Findings after examination
*Diagnosis
*Treatment options and risks
*Agreed treatment plan
*Patient consent
*Risks and complications
In addition, patient records must
contain radiographs, X-rays, laboratory prescriptions, clinical notes, NHS
forms (if relevant) and investigative reports. All information must be clear
and legible and written in permanent or electronic format.
Fact
2: 15% of general
dental practitioners based in the UK are in private practice.
Source: British Dental
Association GB.
3.5 General Format of Dental
Patient Records
How to collate dental records for patient.
Patient Information
Patient information should
include name, address, contact numbers, email address, insurance information
(name of the person or agency responsible for payment), name/address/contact
number of the primary care physician and emergency contact number.
Medical History
The general medical history of
the patient should contain all important information, as this will help to
ensure safe administration of dental services. In particular, the medical
history should address certain key areas, including history of heart disease
and immunodeficiency syndromes, allergies, a detailed list of any medications
and details of past hospitalisation, sickness and other health conditions. The
medical history should contain details of blood transfusions, seizures,
prosthetics, alcohol dependency and so on.
Whilst the medical history form
will be signed and dated by the dentist, the assistant should ensure that the
history is complete, updated and filed away accurately.
Some important questions
regarding medical history could include:-
*Has there been any change in your
health conditions?
*Have you been prescribed any new
medication?
*What was the date of your last
medical/dental check-up?
*Are you breastfeeding or
pregnant? (Female patients).
Ensure that you get all reports
seen, evaluated and initialled by the dentist, before you file away the patient
record. Patient dental records should be protected against unauthorised access,
accidental loss, misuse, damage and corruption. Most dental offices use
automated systems of record keeping and assistants must ensure that all records
are backed up.
Every time a dental record is
modified, the date must be recorded on the system. The DPA or Data Protection
Act is applicable to dental records used in practices in the UK. According to
the DPA, all dental records must be accurately created, carefully maintained
and securely disposed of. All dental professionals in the UK must abide by the principles
of the DPA.
The key points of dental records
are discussed below:-
*Patients must consent to have
information recorded through audio or video.
*Patients should be informed
regarding usage and destruction of records.
*The dental team must bear in mind
that patients and authorised representatives must always be allowed to access
their records. However, the patients do not have any claim over the original
records.
*The office is allowed to charge a
nominal fee for allowing record access.
*The dental practice need not
agree to any changes to the dental records (as a response to a request by the
patient).
*Although the official duration is
two years, the NHS recommends that dental records should be maintained for at
least 11 years.
*Patient confidentiality extends
beyond the death of a patient. In this case, records may only be disclosed if
requested for by an authorised adult.
Confidentiality is central to the
relationship with patients. All members of the dental team, including
non-registered members, should be aware of the importance of patient
confidentiality. Please refrain from sharing any information about patients on
social media sites and so on. In cases where you discuss patient prognosis, etc
professionally, patient identity must be kept anonymous. Similarly, staff
members should avoid discussing patient information in areas where they may be
overheard by others.
At times, you may need to
disclose personal dental information. In such cases, you must explain to the patient
the reasons for disclosure, the information that you will be disclosing and the
likely consequences of the disclosure. Patients who want to withhold permission
to disclose information must be given sufficient opportunity and time to do so.
If the patient has withheld permission, this information must also be recorded. As a member of the dental team,
you may be asked for patient information for the purposes of university
teaching, research and so on.
In such cases, please ensure
that:-
*Patients understand clearly how
the images, photographs, etc will be used.
*Obtain and record written consent
from the patient.
*You release only the minimum
information necessary for the purpose.
*Explain to the patient that it is
possible to withdraw permission at any point of time.
Patient confidentiality extends
to originals and copies of audio and video recordings, radiographs and
photographs, etc. You must refrain from making any recordings in the absence of
patient consent. Whilst transmitting dental record
information over the internet, please ensure that you use encrypted
transmission for added security. Avoid leaving patient information where it can
be viewed by unauthorised public and members of staff.
3.6 Ensure that you have a
consistent Complaints Procedure
Patients expect that their complaints and concerns should
be acknowledged, listened to and addressed promptly.
The dental team must respect the
patient's right to complain and must respond to the complaint in a constructive
and effective manner. All members of the dental team must be trained to handle
complaints.
Ideally, the complaints procedure
should be typed out legibly and placed where patients are able to view it
clearly. The procedure should allow the practice to respond to complaints
effectively, whilst using the information to improve dental services. You must
ensure that any complaints information is kept confidential. Offer the patient
alternative outcomes, ask them what they want and offer them a time limit
within which they can expect a response regarding the complaint. If there are
extenuating circumstances, please keep the patient informed regarding the time
limit within which you will respond to their complaint.
Patient complaints serve as
important feedback on the dental services offered at the clinic.
Ensure that
you respond in writing and explain any practical solutions. Adopt a way of working with other
dental team members, in a way that promotes the best interests of the patient.
Each patient needs to be confident that team members will work effectively
together to provide the best services. Working together as a cohesive and
effective dental team takes patience, effort, courage, time and persistence.
The roles of each member of the dental team should be clearly defined and the
leader should help to build an environment of mutual trust and respect.
Team workers should treat each
other with dignity and respect and must refrain from discrimination. The team
should be aware of their common objectives and must collaborate in promoting
the best interests of patients. All dental team members should maintain and
promote their work within the knowledge or skills that they possess
All members of the dental team
must be trained and qualified to provide different services and it is crucial
to recognise the limits of your competency. For example, a dental assistant
helps the dentist in the treatment room, but is not authorised to perform
surgeries. Dental assistants must be trained to perform tasks that help them to
execute their duties effectively and to the best of their ability. It is
important to undergo Continuing Professional Development (CPD), in order to
help you keep up with the latest knowledge and techniques.
The dental team must raise
concerns, if a patient's welfare is at risk.
Patients expect the dental team
to raise concerns if the health or behaviour of a dental professional is
questionable or increases risk with regard to patient welfare. Staff should be
encouraged to raise concerns, without the fear of reprisals or backlash. If at
any time you feel that a patient is at risk or vulnerable patients are being
exploited, feel free to raise a concern in accordance with the recommended
procedure.
Employees must also feel free to
raise concerns regarding conflict of interest, personal and professional
loyalties. As a dental assistant, you must avoid signing contracts that contain
a “gagging” clause, which prohibits employees from speaking about the office.
Ensure that your behaviour always
helps to maintain patient confidence in you as an individual, as well as the
dental profession on the whole.
As a dental assistant, you must
always maintain cordial and warm relationships with patients, without crossing
the limits of decency and propriety. Ensure that you perform your tasks to the
best of your ability and avoid making disparaging remarks about colleagues and
co-workers. Dental assistants should put forward their best efforts to promote
the interests of patients and should refrain from breaching confidentiality.
Desirable behavioural traits
include empathy, professionalism, competence and effective communication.
Dental assistants are often the link between the clinical and administrative
departments of an office.
Activity 2
Estimated time: 10 minutes
A patient rushes into the dental
office and is in great pain due to toothache. The dentist is busy with another
emergency in the treatment room. How will you manage the situation?
Module Summary
As with conventional medical
practice, dentistry is also associated with unexpected mishaps and emergencies,
despite the best efforts of dental teams. Hence, it is crucial for dental
practices to obtain legal and valid patient consent before every irreversible
and/or invasive procedure.
On the surface, most patients may
seem friendly and cooperative. However, the problems start when something goes
wrong. A disgruntled patient and a skilful lawyer may become a nightmare for
the dentist and their practice. The only way to prevent this situation is by
obtaining valid, fully informed and legal patient consent. The document should
contain clearly specified details of the risks associated with the procedure,
the dentist's acknowledgement of the risks and the patient's comprehension of
the risks.
One of the most fundamental
ethics in the field of dentistry is the confidentiality between doctor and
patient. Although the relationship between a dentist and the patient is a
cordial one, it can sometimes be a source of conflict if you fail to follow the
standards prescribed by the GDC.
It is the duty of the dental
office to observe the rules of confidentiality and refrain from disclosing
patient information to third parties. Although dental patients do not own their
records, they enjoy access to them and the dental practice must comply with the
provisions under the Data Protection Act. Overall, dental assistants must
follow the doctrines explained in the Standards of Ethics stipulated by the
GDC. The patient's best interests are promoted by providing excellent services
that lie within the limits of your skills and competencies.
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