Clinical Record Keeping

Question 1

Describe 4 reasons to keep dental records

Answer 1

1. Help practitioners make diagnosis and carry out appropriate treatment
2. Good continuity of care
3. Enable another clinician to easily understand patient’s current condition
4. Prevent adverse incidents e.g. wrong tooth being treated

Question 2

What is the main dento-legal purpose of keeping records?

Answer 2

Provide evidence which may establish or refute allegations of negligence or poor performance

Question 3

What does the GDC say about record keeping in its “Standards for the Dental Team”?

Answer 3

• Make contemporaneous, complete and accurate record
• Required to protect confidentiality of information
• Obligation to create records for each patient interaction

Question 4

Describe the basic information about records

Answer 4

• All record should be factual and accurate
• Write legibly in black ink
• Ensure all entries are dated signed by clinician (and supervisor)
• Each page should have sticker containing all patient details
• Demonstrate chronology of events and patient treatment
• Abbreviations used based on list provided by SOD

Question 5

What are the 4 C’s in record keeping?

Answer 5

1. Contemporaneous - Made at the time of examination / treatment
2. Clear - Written so everyone can understand them
3. Concise - Convey essential information
4. Complete - Record all aspects of visit

Question 6

Describe the pre examination components of a dental record

Answer 6

• Person details including name, DOB, address and contact details
• Emergency contact information
• Up to date medical history
• Show reason for attendance and any presenting complaints
• If presenting in pain, full pain history carried out
• Dental and social history

Question 7

Describe what should be recorded for each patient examination

Answer 7

• Full details of charting
• Findings on examination (intraoral and extraoral)
• Special investigations
• Diagnosis of any problems

Question 8

Name 4 things which should be recorded on an intra oral examination in the patient’s records

Answer 8

1. Soft / hard tissue examination
2. Any abnormalities
3. BPE
4. Oral hygeine status

Question 9

Describe what should be recorded if a radiograph is taken for a patient

Answer 9

Radiographs must be justified, have a quality assurance score and a full report recorded

Question 10

Describe how an agreed treatment plan should be documented

Answer 10

• Document discussion with patient in formulating plan
• Patient should be informed of options of treatment, risks / benefits, recommended treatment and consequences of no treatment
• Logical and organised
• Check and record patient has fully understood discussion

Question 11

Describe what to record for each patient treatment visit in patient records

Answer 11

• Date of treatment
• Full details of treatment carried out including reason
• Details of LA, medications prescribed and materials used
• Any adverse reactions / complications
• Details of post treatment advice
• Signature of student and supervisor

Question 12

Name 3 potential components of dental records not directly related to a patient visit

Answer 12

1. Photographs
2. Study models / lab documents
3. Referral letters and reports

Question 13

Describe the process of making alteration to dental records

Answer 13

• If errors are identified appropriate amendments can be made
• Make alterations by scoring out then writing corrected entry alongside
• If entry is made in wrong patient’s notes it can be removed with explanation

Question 14

What is the statutory requirement for dental records?

Answer 14

Data Protection Act 1998

Question 15

Describe the Data Protection Act 1998

Answer 15

• Governs how public bodies can process and handle personal data
• Give patients right to apply for access to any information held about them
• Any request should be in writing and information should be forwarded to patient within 40 days

Question 16

Describe the principles of data protection

Answer 16

• Personal data must be accurate and up to date
• Data must be obtained for specified and lawful purpose
• Data should be processed lawfully in transparent manner
• Data shouldn’t be held for longer than necessary
• Integrity and confidentiality

Question 17

Describe confidentiality with regards to record keeping

Answer 17

• All patients are entitled to confidentiality
• Vital information is kept confidential
• Adhere to guidance published by DOH and GDC
• Any disclosure should be discussed with indemnity organisation

Question 18

What is the DOH guidance on retention of records?

Answer 18

Records should be kept for no longer than 30 years and it may be reasonable to store study models or wax ups for shorter due to practical difficulties of storage

Question 19

What is the FGDP / NHS guidance on retention of records for adult patients in community dental care?

Answer 19

Adults it is recommended records should be kept for 11+ years following completion of treatment

Question 20

What is the FGDP / NHS guidance on retention of records for children patients in community dental care?

Answer 20

Should be retained until child is 25 or for 11+ years following completion, whichever is longer

Question 21

What is the FGDP / NHS guidance on retention of records for adult patients in hospital care?

Answer 21

8 years following completion of treatment

Question 22

What is the FGDP / NHS guidance on retention of records for children patients in hospital care?

Answer 22

Until they are 25 or 8 years post death

Question 23

Describe the security of records

Answer 23

• Patient records must be stored securely
• In SOD, paper records in lockable storage in area not available to public
• Records shouldn’t be left out overnight in surgery
• Archived records should be in secure archive storage facility

Question 24

What must a referral letter contain?

Answer 24

Summary of patient’s personal information including relevant medical and dental history with clear indication of condition initiating referral

Question 25

What are 6 common dento-legal pitfalls?

Answer 25

1. Illegibility 2. Lack of detail 3. Alterations to records 4. Breaches of confidentiality 5. Verbal instructions not recorded 6. Amendments to treatment