COVID-19 record keeping

22 April, 2020 / featured
 Angela Harkins  

In advising patients over the phone I appreciate it can be more challenging as you have limited information. In addition to the limited information, you will have to rely on an accurate description from the patient of their signs and symptoms.

In managing patient expectations highlighting the potential for error or inaccuracy of diagnosis due to the limitations of telephone dentistry should be referenced in every telephone patient triage.

I would advise an important aspect of emergency telephone care is record keeping.

I would suggest for all patients a detailed record of the telephone consultation and outcome is kept:

  1. Verbal update of medical history
  1. Details of any medications already taken
  2. Description of signs and symptoms – you could ask the patient to take a photo and email or consider the option of face timing the patient if in doubt
  3. Note all advice and options discussed
  4. Note the type, dosage, and quantity of painkillers
  5. If antibiotics are provided a clear clinical justification and diagnosis should be recorded
  6. Contact local pharmacy to arrange remote prescribing
  7. Ask for permission from the patient to use an up to date email address to contact them
  8. Advise in an email if you have any concerns the patient did not fully understand the instructions or care advised over the telephone
  9. Know the referral pathway to NHS Urgent Dental Care HUB for patients who require dental treatment beyond pain and infection management.
  10. Keep updated with referral waiting times for patients with urgent treatment who need to be seen in a UDC HUB

In addition, keep a note of the date and time of patients whom you have tried to contact for emergency advice and did not respond when called back.

If I can offer any further advice or support in this matter, please do not hesitate to get in touch by email angela@tdsew.com  or call 0141 772 0178.

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