Autonotes are common in dental records. They can be everything from a computer-generated sentence inserted by pressing a shortcut key to whole accounts of the treatment carried out.

In themselves there is nothing wrong with autonotes but they do threaten to damage the dentist’s greatest advantage in a negligence claim: the sanctity of contemporaneous records.

Contemporaneous records are often the silver bullet in medical and dental negligence claims. Most claims are at least a year old before there is any real progress. The cause of action and the factual scenario will therefore be completely lost to the clinician’s memory in the majority of cases.

The patient will have a memory of events by the very fact that something occurred that has caused them to complain. But we all know that patient recollections can be vague, poor and not uncommonly, simply wrong.

If you have a contemporaneous note of what happened it will do several things:

Firstly, if the notes look like they are comprehensive, well maintained and legible then they alone can create an impression to a claimant’s advisors or a court. You all do them differently. I can pretty much guess how old you are from looking at the notes you make. I can tell whether you qualified in the 60′s or just last year. I will form an opinion within a few minutes as to whether you are any good at your job. Unfair? Maybe, but if I do that so will a judge. In short the lawyers already have an idea what they’re dealing with before they’ve read a word.

Secondly, it will jog your memory which, when coupled with the detailed allegations from your former patient, will enable you to build up a picture of what happened.

Thirdly, if there is an in-court dispute as to what happened or what was said then you have the upper hand. The battle will be between an upset and angry patient who has probably very little grasp of the anatomy of their mouth and a professional with an understanding of the radiographs and charts who made a contemporaneous note.

Judges LOVE contemporaneous notes. I have seen whole cases turn on the existence of one written sentence. The rationale is that the note was made at a time when litigation was not contemplated. The writer didn’t know then that the dispute would arise. Therefore the note is more likely than not to be true thinks the judicial mind. Why would it be made up? There can be a suspicion either that it was added in later (not possible with modern software packages) or that it was a back-covering exercise. Obviously the latter is more likely when everyone agrees there and then that something has gone wrong. When the wrong tooth has been taken out for example, what the dentist writes afterwards is more likely to be self-serving than in other situations.

So what’s my beef with autonotes?

They threaten that sanctity. What if, by pressing a keyboard shortcut, you can add in a sanitised account of a standard procedure. It saves a lot of time, it assists in complying with the duty to record. It covers your back. But what if it, or another autonote on your system, is demonstrably a fiction? There goes your silver bullet; there goes your credibility.

Let me give you an example.

A lady had an upper 7 extraction. The palatal root was left behind. She suffered for several months before going to a new practice who found it on radiograph. The dispute is that she says she wasn’t told that the root was retained.

The defendant dentist is adamant she told her.

The autonote was something along these lines:

“Consent gained for todays treatment.
Local anaesthesia 1.8mls Lignocaine batch number 12345 exp date 0912
Tooth extracted.
Apices intact. Pt warned of possibility of minor apex retention.
Haemostasis achieved.
POIG orally and in written form.”

That’s all very well but what if the next note entered on the same day is:

“tooth frectured [sic] several times, evelated, [sic] took long time”

It’s pretty clear that this was a difficult extraction that didn’t go well. That is reflected in the second note but not the first. You’ll notice that you don’t see spelling mistakes in autonotes but you often do in in the true contemporaneous note.

The note that there was a warning about the retained root is within the autonote that carries very little probative value. It simply makes the practitioner look like the type to take shortcuts, like someone who pays lip service to note-taking.

What should and could have been the note that saw off the claim is in fact now an indication that the notes do not represent the true situation. Credibility is lost. You might still win the argument but possibly not without convincing a judge in the witness box.

Use them by all means but please bear the above in mind.

This article was not written with the aid of an autonote.