Importance on records

Question 1

Outline

Answer 1

accurate dental records are essential to ensure that pts receive necessary, appropriate + safe trt. Poor record keeping often forms basis of pt complaints that cannot be defended + dentists are ultimately responsible for their errors + omissions unless notes were written to record trt provided by dcp

Question 2

Errors or omissions

Answer 2

in recording info may result in incorrect trt being carried out or failure to provide necessary trt

Question 3

Establishing identity

Answer 3

in fatal accidents where facial features are destroyed, the teeth are often unaffected + can be compared with dentists’ records to identify a victim

Question 4

Allow correct trt planning + past trt

Answer 4

they form the basis on which fees are calculated + accounts rendered to pts

Question 5

FTAs + refusals of trt

Answer 5

are noted + pts attitude to oral health, as well as any risk factors to good OH can be assessed. Appropriate recall arrangements can be made for each pt, in line with guide lines of the National Institute for Health + Clinical Excellence (NICE)

Question 6

They should be retained for

Answer 6

at least 11 years after completion of trt, or to the age of 25 years in the case of children’s records.

Question 7

Also

Answer 7

many difficulties concerning pts can be prevented if complete records are available to all attendances at practice, while no time is wasted in putting such info at the dentist’s disposal. Recording + filling systems may vary - records must always be accurate, legible, comprehensive + easily accessible