When are notes contemporaneous?

3D clocks

  • Contemporaneous – This is defined as an accurate record, made at the time, or as soon after the event as practicable. It is a record of relevant evidence which is seen, heard or done, by the maker of the note. EVIDENCE ACT 1995 – SECT 72.
  • Contemporaneous – records should be made at, or very close to, the time of the examination, treatment, observation or discussion, and they should be dated and signed legibly. Dental Defence Union

I was a relatively early adopter of computers in practice management, an Amstrad PCW256 in 1988 was followed by something that ran on 4.5″ floppy discs in 1990. Finally a very neat little system called Dental Practice which was put together by a dentist and his brother, a programmer. This was bought out by Denplan, sold on to a supplier subsidiary of Henry Schein, possibly Kent Dental or Rexodent, then left to wither on the vine and finally became part of the SoE empire when the users were told that it wouldn’t be supported any longer so why not move to Exact? A friend of mine explained the means of the growth of computer software, and other, companies this way, “buy up the opposition and close them down”.

The one area that I resisted, through choice not by being a laggard, was the writing of clinical notes.  I was taught both as an undergraduate in Newcastle and especially during my six months in the trenches as one of two resident housemen in Oral Surgery at The London Hospital that my notes were to be coherent, comprehensive and contemporary. It didn’t matter where you were, what the time was or who was waiting for you, write up full notes and sign them. “Be prepared to stand in a courtroom in 10 years” said Brian Littler one of the two Senior Registrars, “and be cross examined, with only your notes to remind you of what went on.” My handwriting isn’t the best, but it is mine. My thoughts in those days were pretty coherent because of the excellent systems that we were taught and the notes reflected that. (I did have to write a report some 10 years later about one incident that lasted fewer than 20 seconds yet had repercussions. My notes, forwarded by the investigators, brought everything sharply into focus.)

“Never ever let anyone else write your notes”, I was told, “certainly don’t delegate them unless you can read everything that has been written and can amend and then countersign it.”

Having worked in (quite) a few practices after selling, and before establishing myself with enough coaching and consultancy work to keep body and soul together, I came across some variations in the way that notes were written. By now probably 60% – 70% of practices were able to write notes using the computer software. My feelings then, and still, are that too often the software is driving the record keeping process rather than the other way round.

  • Nurses writing everything and closing the notes before I could see them.
  • Branded as a troublemaker for insisting on seeing and checking the patients’ medical histories.
  • A nurse criticising me for being picky for writing ridiculously long notes that, “nobody will ever read.”
  • Being told that there was no time to write the (paper) notes and that I would have to do them at the end of the session.
  • Not being happy with the treatment screens meaning that I “only” had to adapt to and make my notes fit the proformas.

So I was concerned to read of a new set up on one of the leading software suppliers’ systems which means that,  “you can now charge whatever you want through but have the rest of the day to alter and finish your notes on that same patient without having the notes locked”.

That doesn’t sound like the notes will be contemporaneous to me, but perhaps people have better memories than I did?

 

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