How to record a complication in HOF

A complication happens, sooner or later, in the routine of anyone who does orofacial harmonization. It might be a bruise larger than expected, a local reaction, an asymmetry the patient notices, a suspected vascular occlusion, a fainting episode, a nodule that appears weeks later. What sets a mature clinic apart is not never having complications, but how it cares, how it records and how it communicates. Care comes first. The record follows right after. And communication with the patient runs through all of it.

This page covers recording and communication, from the standpoint of management and documentation. It is not a clinical protocol and not legal advice. Clinical management is covered in the specific safety and complications pages, such as safety and complications: overview and recording the complication in the patient record. The focus here is: what to write down, in what order, how to talk to the patient and how to organize the clinic for it.

Why recording well protects everyone

The complication record serves four purposes:

1. Continuity of care. Whoever sees the patient later will know what happened and what was done.
2. Learning. The clinic identifies patterns and adjusts its processes.
3. Patient protection. There is a record of what happened and of the instructions received.
4. Professional protection. A contemporaneous, consistent record shows diligence.

A blank patient record, or one written days later with vague dates, weakens both the defense and the care. On the other hand, the record never replaces care and must never delay clinical action: in an emergency, treat first and record as soon as possible.

What to record: essential fields

A useful record answers simple questions. Structure it in fields to make it easy to read and search:

The complication form template has these fields ready to print or adapt. Combine it with the follow-up and progress form.

Contemporaneous and late entries

Whenever possible, write during or right after the event. If the entry is made later, identify:

• the date and time the entry was written;
• that it is a later entry;
• the source of the information (memory, team account, messages);
• who is writing.

Never delete, replace or rewrite what has already been recorded. Addenda must be dated and signed. In electronic systems, check that the change history is preserved. See electronic patient records for HOF for selection criteria, and LGPD in the clinic's patient records and photos (LGPD is Brazil's data protection law).

How to communicate with the patient

Communication is part of the duty to inform. It should be clear, human and honest, never defensive. Principles that tend to help:

1. Speak early. The patient should not find out from the internet or from another professional.
2. Use plain language, avoid terms that hide things and jargon that frightens.
3. Describe what happened without downplaying or dramatizing.
4. Say what will be done now and in the coming days.
5. Agree on a contact channel, with a schedule and a person responsible.
6. Do not assign blame to anyone in the conversation, including the patient.
7. Record the conversation, with what was said and agreed.

Communication in serious cases may involve the professional liability insurer, the professional board and an adverse event report, depending on the case. See professional liability insurance in HOF and adverse event reporting (Notivisa). The phone script for a complication helps structure the first contact.

Short record template

This template is an organizational outline. The clinical action, the mandatory content of the patient record and the way of communicating follow the professional's judgment and the rules of their board.

What to do with the lessons

Once the patient is safe, the clinic can learn. A short review, without hunting for culprits, usually includes:

The idea comes from the concept of a near miss: learning from what happened and from what almost happened. To structure the meeting, see weekly HOF team meeting and clinic process manual.

Preparing before it happens

The best time to set up the record is before the first event. Have ready:

Harmy and complication records

Harmy is not a patient record system and does not record complications. The app stores projection sessions by patient and the actual-result photo, which can help document the starting point and progression visually, but the clinical record of the event belongs in the clinic's patient record. The app's images are illustrative simulations and must not be used to prove clinical results.

Recording well is a habit built with routine and ready-made templates. When the complication arrives, the clinic that already has the path mapped out cares for the patient better and writes down what happened better.