In dentistry, audio recordings of consultations offer a range of benefits to both dental practitioners and patients. In this article, we'll explore the key benefits of audio recording dental consultations, why it's worth considering for your practice and what you need to know to implement audio recording yourself.
As dental professionals, we are lifelong subscribers to "complete, accurate, and contemporaneous", striving to document "as much detail as possible" (GDC Standards 4.1.1 & 4.1.2).
The patient record is comprised of data from a wide range of technologies including photographs, charting, x-rays, models, 3D scans, emails, letters, phone calls, and of course, written notes. Written notes are crucial for a succinct, salient record of important information, treatment plans and decisions. But when it comes to a record of the deep and meaningful conversations clinicians and patients share, despite our best efforts the written record suffers from omissions, lack of detail and inconsistent quality. A trilemma; Complete, accurate, contemporaneous. Choose two.
An audio recording enables us to enjoy all three. It provides a master record of our consultations and the decision-making process that our patients have worked through with our guidance. It is complete, it is accurate and it is immediate. It includes all the nuances, the exact words, as well as the tone and manner in which information has been received. In the same way that photographs add colour and context to charting, audio recordings provide accuracy, completeness and context to the written record.
Making an audio recording does not replace the need to make a thorough clinical record of the diagnosis, consultation and treatment. Audio should be considered an adjunct to the written records rather than a replacement for them, reducing the burden on the written word alone, and on those trying to type or write that fast.
As caring professionals, we are often at our happiest when we are in flow, serving our patients with great consultations, helping them to understand their options and supporting them to make good decisions for their own health.
Audio recordings enable practitioners to be fully present with the patient making the most of the limited valuable time, with a record of what really happens, not just what we manage to write down. For new patients especially, those early conversations are incredibly rich in information in both directions between patient and clinician.
In an emergency appointment, audio records mean you can be more efficient with your information exchange and enable the team to get on with preparing to help the patient at the same time.
Experienced dentists, with more complex cases, often use a TCO for best practice valid consent. Audio recording can really help a TCO who may not have someone present in the surgery to write their records for them, and who may have the longest and most detailed discussions of all.
Patients are of course entitled to a copy of their records. Offering to share a copy of the audio allows time for patients to review and fully consider options when deciding and consenting to a course of treatment. Older patients may feel particularly supported by being offered this as a service to them, building trust and an open, honest relationship with patients and their support network.
There are clinicians who have successfully implemented audio recording into their workflow and champion the benefits they experience.
You will need a microphone, a recording application and secure storage. Further, to manage this yourself, you will need to satisfy the defined and recommended requirements of the ICO, GDPR, NHS DSPT, GDC and CGDent to ensure privacy, timely accessibility for future treating clinicians, security and storage compliance, and find a way to document the appropriate level of consent.
Microphone selection and positioning make the greatest difference to audio quality and will vary somewhat depending on surgery size and design. The base threshold for quality is a record that is intelligible when listening back. Dictaphones provide good options for positioning and support some useful additional features.
Accessibility of this recording can prove challenging for future clinicians. The use of a mobile phone introduces security and privacy complications. If using a microphone connected to your practice PC, open-source audio recording software is freely available providing standard file formats such as .mp3, or .wav. Storage and processing of such large files can be a challenge for existing practice servers.
File names should avoid any directly personally identifiable information of the patient. Using a date-time or the unique patient ID from your practice management system are appropriate options.
Once created, the audio file will need to be kept for a minimum of 11 years. Files should be well organised, stored in a secure location and encrypted using AES-256 or greater. The nature of your IT infrastructure will determine the most appropriate way of achieving this and you should seek advice from your IT partner. If considering off-site (cloud) storage options, your provider must store the data in the UK, encrypt data at rest and ensure access is only provided to authenticated persons. Cloud options can simplify sharing the audio with a patient on request if the equivalent levels of security can be applied using a shared link or equivalent. All data transfers must be encrypted using HTTPS.
Before recording, the patient will need to grant consent for the recording which too will require documentation. Starting your audio record with this request and the patient’s response can result in a smooth process. Plan and practice a consent statement such as:
“We’re going to have a good conversation and share a lot of information together today. May we make an audio recording to form part of your patient record? You can ask me to stop it at any time and of course, you can have a copy if you think it will be helpful for you to listen back again. It will allow me to concentrate on you right now instead of on my screen”.
If a patient would prefer to decline then stop recording; otherwise continue. When using audio recording becomes a regular practice, you should consider formalising a practice policy detailing how recordings will be stored and who will have access to recordings.
Introduce the idea of audio recording to your team early to ensure they are onboard, comfortable and understand the intent of recording. Audio recordings support, protect and reduce stress for your whole team, especially any involved in the record-keeping process. They reduce risk and give the opportunity for genuine reflective practice following a good outcome.
In addition to ensuring you have the most complete, accurate and contemporaneous record, the use of clinical audio records allows you to be in the moment with your patient, concentrate on communication and better understand the patient’s perspective making positive outcomes more likely.
Before you embark on this journey yourself, know that Dental Audio Notes takes care of all of these requirements for you.
Dental Audio Notes (DAN) is software that runs on your surgery PC. When you are ready, just press record, and you are making the most complete, accurate and immediate clinical record of your consultation. DAN manages all the security, privacy, storage, access and sharing for you, so all you need to do is press go.
In addition, DAN transcribes the audio, and you can tag and annotate the record too.
Just sign up and get started for free to start mastering your record keeping now.
