Clinical Record Keeping Flashcards
Describe 4 reasons to keep dental records
- Help practitioners make diagnosis and carry out appropriate treatment
- Good continuity of care
- Enable another clinician to easily understand patient’s current condition
- Prevent adverse incidents e.g. wrong tooth being treated
What is the main dento-legal purpose of keeping records?
Provide evidence which may establish or refute allegations of negligence or poor performance
What does the GDC say about record keeping in its “Standards for the Dental Team”?
- Make contemporaneous, complete and accurate record
- Required to protect confidentiality of information
- Obligation to create records for each patient interaction
Describe the basic information about records
- 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
What are the 4 C’s in record keeping?
- Contemporaneous - Made at the time of examination / treatment
- Clear - Written so everyone can understand them
- Concise - Convey essential information
- Complete - Record all aspects of visit
Describe the pre examination components of a dental record
- 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
Describe what should be recorded for each patient examination
- Full details of charting
- Findings on examination (intraoral and extraoral)
- Special investigations
- Diagnosis of any problems
Name 4 things which should be recorded on an intra oral examination in the patient’s records
- Soft / hard tissue examination
- Any abnormalities
- BPE
- Oral hygeine status
Describe what should be recorded if a radiograph is taken for a patient
Radiographs must be justified, have a quality assurance score and a full report recorded
Describe how an agreed treatment plan should be documented
- 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
Describe what to record for each patient treatment visit in patient records
- 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
Name 3 potential components of dental records not directly related to a patient visit
- Photographs
- Study models / lab documents
- Referral letters and reports
Describe the process of making alteration to dental records
- 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
What is the statutory requirement for dental records?
Data Protection Act 1998
Describe the Data Protection Act 1998
- 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
Describe the principles of data protection
- 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
Describe confidentiality with regards to record keeping
- 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
What is the DOH guidance on retention of records?
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
What is the FGDP / NHS guidance on retention of records for adult patients in community dental care?
Adults it is recommended records should be kept for 11+ years following completion of treatment
What is the FGDP / NHS guidance on retention of records for children patients in community dental care?
Should be retained until child is 25 or for 11+ years following completion, whichever is longer
What is the FGDP / NHS guidance on retention of records for adult patients in hospital care?
8 years following completion of treatment
What is the FGDP / NHS guidance on retention of records for children patients in hospital care?
Until they are 25 or 8 years post death
Describe the security of records
- 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
What must a referral letter contain?
Summary of patient’s personal information including relevant medical and dental history with clear indication of condition initiating referral
What are 6 common dento-legal pitfalls?
- Illegibility
- Lack of detail
- Alterations to records
- Breaches of confidentiality
- Verbal instructions not recorded
- Amendments to treatment
