Risk Management
- Principles of record keeping/documentation
- Concepts of professional liability
- Risk management protocols
- Legalresponsibilitiesin patient caremanagement
- Legal responsibilities in personnel management
- Management of patient information
- Quality assurance
November 4, 2024
Reflection
Risk Management/Informed Consent
Risk management is a crucial component of
clinical practice, as it ensures patient safety, minimizes errors, and provides
legal protection for both the practitioner and the patient. One key element of
risk management is meticulous documentation. This includes accurate recording
of patient data, such as medical and dental history, medications, chief
complaint, intra and extra-oral examination, radiographic findings, medical
alerts, treatment plans, informed consent/refusal forms, medical consultations,
referrals, and patient tolerance for the procedure and compliance rate. These
documents serve as a legal record of the care provided and are essential in
case of any legal or ethical disputes. In my clinical experience, I have
learned that thorough documentation in every appointment is vital. For example,
during a patient’s periodontal maintenance appointment, the completion of
progress notes detailing the procedure, findings, and recommendations ensures
that the patient's history is accurately tracked. The documentation also
provides clear communication to the rest of the dental team for continuity of
care.
Informed consent is another essential aspect
of risk management, as it reflects the ethical duty to involve patients in
their treatment planning. This includes explaining the proposed treatments,
associated risks, potential side effects, and alternative options. For
instance, for a whitening tray, explaining the benefits is necessary, such as
one of the most effective ways to whiten teeth. Obtain patient consent before
proceeding, where it’s essential to outline the purpose, steps involved and
potential discomfort or risks involved. One of the challenges in applying risk
management and informed consent is ensuring that the patient fully understands
the information provided, especially when there are language barriers or
cognitive impairments. I learned the importance of simplifying complex medical
terms and using visual aids when necessary, as well as ensuring that patients
could ask questions.
I
plan to refine my skills in documenting patient care and improve my
communication techniques during informed consent. My goal is to ensure that
patients are fully informed and comfortable with their treatment decisions
while maintaining accurate and detailed clinical records that support high
standards of patient care and legal protection. Additionally, I will continue
to educate myself on updates in risk management strategies and legal guidelines
to enhance my competency in this area.