Governance Systems for Safety and Quality Policy

HEALTH RECORDS

Stender Dental Studio’s Health Records Policy

Dental practitioners have a professional and legal responsibility to create, maintain, retain, transfer, dispose of, correct, provide access, store securely, and safeguard against loss or damage of health records in accordance with relevant standards, guidelines and legislation, including:

• The Dental Board of Australia’s Guidelines on Dental Records
• The privacy law, Commonwealth Privacy Act 1988, the Office of the Australian Information Commissioner- Australian Privacy Principles
• Australian Commission on Safety and Quality in Health Care – National Safety and Quality Health Service Standards

Stender Dental Studio’s Health Records Process

The practice has elected to use Praktika Dental Software to ensure that an accurate and integrated patient health record is documented and maintained. Patient health records include dental, medical and medications information.

This system ensures patient health records are readily available to dental practitioners and dental staff at the point of care (in the room where the patient is being treated). This system also allows for systematic review of the contents of a patient’s health record as an evidence-base when required.

Access to and dissemination of patient clinical information is restricted to authorised dental practitioners and staff, by:

• Secure storage of OPG and archived Radiographs away from patient access
• Locked filing units
• Maintaining a key register for authorised personnel
• Using Individual login details for electronic systems
• Restricting access to the premises
• Installing an alarm system to protect records
• Ensuring electronic records are protected
• Use of mediref for all patient information and correspondence

Collecting Information

Stender Dental Studio has developed and implemented processes for collecting information about pre-existing healthcare associated infections, communicable disease status, known allergies and adverse drug reactions upon presentation of a patient for care. One of the mechanisms for acquiring this information is the collection and recording of a comprehensive medical/medication history to ensure minimisation of risk and adverse reactions/events.

A medical and medication history is required to be obtained for new patients prior to the provision of care, and is updated at regular intervals of no more than 12 months.

Principal Dentist requires dental practitioners to routinely (at each appointment) ask patients for updates to their medical/medication history.

The medical and medication histories are to include at least three patient identifiers, and where appropriate:

• The medical practitioner’s name and contact details
• The patient’s emergency contact details
• Dental history
• Past and present illnesses and conditions
• Past and present communicable disease status
• Allergies
• Adverse drug reactions
• Present medications
• Identification of ‘at risk’ groups

PATIENT RIGHTS

Introduction

Within Australia, the Australian Charter of Healthcare Rights (ACHR) applies to the entire healthcare system, and it allows patients, consumers, families, carers and healthcare providers to have a common understanding of the rights of people receiving healthcare. The rights included in the ACHR relate to access, safety, respect, communication, participation, privacy and comment.

Stender Dental Studio’s Patient Rights Policy

Stender Dental Studio has developed the following practice specific charter of patient rights that is consistent with the Australian Charter of Healthcare Rights.

Stender Dental Studio’s Charter of Patient Rights

Appointments

Stender Dental Studio aims to provide patients with appointments to meet their treatment needs. It is requested patients make an agreed appointment time and date to assist the scheduling process, notifying the practice where this appointment cannot be met. To assist you in providing us with this information we contact patients by:

• Advanced Booking Recall System
• Calling or Texting 3 weeks beforehand to confirm this appointment
• 48 hours before courtesy texts are sent regarding the appointment time scheduled. Patients can request their best method of contact e.g. telephone, email, SMS, postal reminders.
• These notifications are a courtesy only.

The cancellation policy of Stender Dental Studio requires 24-48 hours’ notice for cancellation of an appointment. Should the patient cancel without the required notice period there is a cancellation fee of $50 per hour appointment.

In the event we are unable to accommodate a patient’s request for an appointment at a specific time/date, consultation with the treating dental practitioner will be sought.

Safety

All patients are required to complete a full medical and medication history as accurately and completely as possible, to allow practitioners and staff to identify any circumstances that may increase the risks associated with dental care.

In the unlikely occurrence of an adverse event, dental practitioners at Stender Dental Studio have a responsibility to be open and honest in communications with the patient involved, and families or carers if applicable.

It is the responsibility of the registered dental practitioner, in accordance with the Dental Board of Australia’s Code of Conduct for Registered Health Practitioners, to explain to the patient what happened and why, as well as offering support and advice with regard to how the situation can best be resolved or managed.

Open Disclosure

Upon recognising the occurrence of an adverse event, the dental practitioner will follow our Open Disclosure Process, which aligns with the Australian Commission on Safety and Quality in Healthcare’s Open Disclosure Framework, as outlined below:

• Act immediately to rectify the problem, if possible, including seeking any necessary help and advice.
• Explain to the patient, in sufficient detail, so the patient understands what has occurred, including the anticipated short-term and long-term consequences.
• Acknowledge any patient distress and provide appropriate support.
• Develop a future management plan for the patient if required.
• Ensure that the patient has access to information about the process for making a complaint.

Sufficient detail is to be recorded in patient records to reflect the information provided to the patient about the incident, associated risks and likely consequences. The dental practitioner will notify the occurrence of the adverse event to their professional indemnity insurer, consistent with the clauses of their policy.

Respect

Stender Dental Studio values all patients as a unique person and hope that at all times we can provide dental treatment in a manner that is respectful of their culture, beliefs, values and personal characteristics. Patients are asked to reciprocate this respect by being mindful of all staff and other patients.

Communication and decision making

Stender Dental Studio respects the patient’s right to receive adequate information to make informed decisions regarding their health and healthcare. Consequently, all staff should continually demonstrate a commitment to providing patients with accessible and understandable information about their treatment and treatment options, including costs, proposed medications and risks involved. We do expect patients to actively participate in decisions and choices about their treatment and dental needs, involving family or carers where required.

This should also include maintaining suitable evidence that patients are fully informed about their proposed treatment and have been a partner in the development of their treatment plan. Such evidence will be monitored through the practices records monitoring and review processes.

Informed Consent Process

The initial examination of a patient shall be considered ‘implied consent’ to that procedure based on the booking of an appointment, attendance, and the patient allowing the physical examination to occur. Any subsequent treatment shall require the patient to make an informed decision and consent to the treatment either verbally or in writing depending on the procedure and associated risks.

The dental practitioner who is to perform the treatment is responsible for the following informed consent process in line with the Dental Board of Australia’s Code of Conduct for Registered Health Practitioners.

A patient will be:

• Informed (or receive information in some other way) what procedure is being proposed
• Informed (or receive information in some other way) about the possible risks and benefits of the treatment in a form or manner they can understand
• Informed of the risks and benefits of all options
• Afforded the opportunity to ask questions and receive answers that meet with their satisfaction
• Afforded sufficient time (if needed) to discuss the plan with their family, carer or advisor, especially for complex treatment plans
• Fully informed of and comprehending the cost of treatment
• Able to use the information provided to help them make a decision they believe is in their best interest, in the absence of any coercion from the dental practitioner
• Afforded the opportunity to communicate their decision to the dental practitioner either verbally or in writing

Dental practitioners are required to provide relevant documentation to the patient about the proposed treatment. The practice also requires dental practitioners to use their clinical judgement to determine where written consent is required from the patient and/or carer.

Dental practitioners shall take into account additional considerations regarding guardianship arrangements for consent matters when dealing with vulnerable patients.

Sufficient detail is to be recorded in patient records to reflect the information provided to the patient associated with their treatment options and the treatment plan, which is ultimately agreed upon.

Informed consent documentation

All informed consent documentation used is reviewed at regular intervals and any updates to these documents are designed to improve patient understanding and the quality of care provided.

Privacy

In accordance with the privacy law, Commonwealth Privacy Act 1988, the Dental Board of Australia’s Code of Conduct for Registered Health Practitioners, the Office of the Australian Information Commissioner- Australian Privacy Principles, a patient can expect their personal health and other information will be collected, used, disclosed and stored in accordance with relevant laws about privacy, and this information will remain confidential unless the law allows disclosure or the patient directs us to release the information.

The Privacy Policy of Stender Dental Studio consists of the following:

• All information collected from the patient will be used for the purpose of providing treatment. Personal information such as name, address and health insurance details will be used for the purpose of addressing accounts to the patient, as well as processing payments and writing to the patient about any issues affecting their treatment.
• We may disclose a patient’s health information to other health care professionals, or require it from them if, in our judgement, it is necessary in the context of the patient’s treatment. In this event, disclosure of personal details will be minimised wherever possible.
• We may also use parts of a patient’s health information for research purposes, in study groups or at seminars as this may provide benefit to other patients. Should that happen, a patient’s personal identity would not be disclosed without their consent to do so.
• Patient history, treatment records, X-rays and any other material relevant to treatment will be kept and remain in a secure environment.
• Under the privacy law, patients have rights of access to dental information held about them by this practice. We welcome a patient to inspect or request copies of their treatment records at any time, or seek an explanation from the dentist. The following procedure has been developed to ensure that all requests for access are dealt with as efficiently as possible:

• All requests for access (other than straightforward requests for copies of test or treatment results made to your dentist during your consultation) should be made in writing using (where available) a Request for Release of Dental Records Form.
• Requests for access will be acknowledged by the practice within 48 hours of the receipt of the request.
• Where it is not possible for access to be granted within 30 days, the patient will be notified/advised when and if access will be granted.
• Where access is refused, the patient will be advised in writing of the reasons for refusal. This will include any information about other means by which access may be facilitated.
• A patient will not be permitted to remove any of the contents of their dental file from the practice, nor will they be permitted to alter or erase information contained in the dental record. However, if any of the information we have about a patient is inaccurate, a patient is encouraged to ask us to alter their records accordingly, in writing.
• When a request for copies of dental records is received, a fee of $22 is required to be paid by the patient. It is policy of Stender Dental Studio to provide a covering letter for all record transfers.
• Generally, records will be transferred by the practice (on behalf of consenting patients) from one treating practitioner to another. In limited circumstances patients will be required to collect their records in person or may request in writing that records are provided to another authorised person.
• If a patient, or authorised person, is collecting a copy of dental records, they may be required to provide identification. Where possible this should be photographic identification.
• It is a policy of Stender Dental Studio that if records are collected by a patient or authorised person that an appointment is made to discuss the records as part of this transfer.
• An administration fee of $22 per patient or $55 per family is required for duplication of records.
• All records are transferred either hard copy, certified mail or mediref

Comment

A patient’s evaluation of the care received at our practice is an extremely important form of feedback that provides valuable information about the services we provide. We encourage patients to provide both positive and negative feedback.

All staff will be provided with training and support that will assist them to identify, report and appropriately respond to complaints and other negative feedback. At Stender Dental Studio we classify negative feedback into three categories:

1. Enquiries: low level matters where an explanation or clarification of circumstances satisfies or resolves the patient’s concerns. No further risk or future action against the dental practitioner or practice is indicated
2. Notification: a complication or incident that has not caused the patient to make any complaint or claim, but has the potential to become a complaint or claim in the future. The dental practitioner involved will consult their professional association in these matters for guidance on handling the incident and whether notification to the professional indemnity insurer is required. The dental practitioner’s management of such complications or incident will be compatible with the practice’s open disclosure process.
3. Complaint or Claim: matters in which a patient, or person on behalf of the patient, has made a verbal or written complaint to the practitioner or to a statutory or legal body, regarding some element of treatment that has been provided by the dental practitioner to the patient. The dental practitioner involved will consult their professional association and their professional indemnity insurer prior to responding to the matter.

In the event of a patient complaint, all staff at Stender Dental Studio should use the following complaint handling policy:

• Provide an open environment for a patient to share their dissatisfaction with us directly, whilst respecting the patient’s right to have a concern heard by an independent third party such as the Dental Board of Australia or The Western Australia Dental Association Dental Cases Committee
• Resolve the complaint at the lowest level possible.
• A patient will be required to place serious complaints or requests for refunds in writing.
• Notification to and advice sought from professional associations and professional indemnity insurers is encouraged.

Complaint Handling Process

Complaints will be acknowledged and responded to in a timely manner, either verbally or in writing, in respect to the seriousness of the complaint. We aim to respond to all complaints within 14days with a maximum of 30 days if the practitioner is not available to address the concern. All complaints will be recorded in the Compliments & Complaints Register.

All complaints will be reported and reviewed by the Principal Dentist of the practice. Responsibility for the management of practitioner related complaints will lie with the dental practitioner about whom the complaint is related. The dental practitioner involved will respond to the complaint upon receipt of advice from their professional association and/or their insurer.

Complaints Review Process

Stender Dental Studio is committed to continuous improvement in safety and quality. The Principal Dentist will analyse data/feedback from the Compliments & Complaints Register and take action where required. Any review actions/outcomes will be communicated to staff.

Notifying patients about their rights

Stender Dental Studio will always endeavour to advise patients about their rights and the way our practice operates. Part of the process of providing this information to patients and/or careers is providing access to our practice Charter of Patient Rights.

All staff will assist patients to understand their patient rights and the way our practice operates. It is the responsibility of staff to proactively identify those patients who may be ‘at risk’ of not understanding their healthcare rights and to consult the dental practitioner if further guidance is needed.