Table 1 A summary of the key elements of dental record-keeping
From: Note bloat
Accuracy and clarity | All entries must be precise and unambiguous, ensuring that the information is correct and easily understood by other healthcare professionals who may be involved in the patient's care. Avoid unnecessary jargon and ensure clarity in all documentation |
Comprehensive documentation | Records should cover all essential aspects of patient care, including medical and dental history, diagnosis, treatment plans, procedures and outcomes. They must also include discussions of risks, benefits, alternatives, patient preferences, and any follow-up instructions, advice or care provided. It is also prudent to record the patient's compliance to advice - from a dento-legal perspective, a non-compliant patient helps to advance the contributory negligence argument - for example in cases relating to periodontal disease progression |
Timeliness | Documentation should be completed as soon as possible after the patient interaction to ensure accuracy and prevent memory gaps. Any delay in writing of the record increases the risk of omitting important information.11 This helps maintain a contemporaneous record (we take ‘contemporaneous' to mean writing the notes before the next patient is seen in the dentist's appointment schedule) which is vital in defending the care provided in any future legal or regulatory review especially when addressing concerns that arise long after care has been provided. While civil claims must be filed within three years of the alleged negligence or when the patient becomes aware of it, GDC investigations have no time limit |
Legibility | Whether handwritten or digital, records must be easily readable. Poor handwriting or unclear digital formatting can lead to misinterpretation and compromise patient safety or legal defence |
Confidentiality | Patient records must be stored securely and accessed only by authorised personnel, in compliance with data protection laws like General Data Protection Regulation. This ensures patient privacy and builds trust in the healthcare system |
Continuity of care | Ensure that records support continuity by documenting all relevant communications, referrals, handovers and follow-up appointments. This ensures that other healthcare providers can seamlessly continue the care of the patient based on the documented history |
Audit | In digital systems, every entry, edit and amendment should be tracked with an audit trail showing who made the change, when and why. This transparency ensures the integrity of the records and helps identify any unauthorised alterations |
Professional responsibility | The treating clinician is ultimately responsible for ensuring that the records accurately reflect the care provided. Even if assistants or other staff are involved in record-keeping, the clinician must review, verify and amend the records as necessary |
Consent and communication | Documenting informed consent is crucial. This not only involves recording that consent was given but also ensuring the patient's understanding of the risks, benefits and alternatives discussed. Discussions must be noted to protect against potential future complaints or legal challenges |
