Legislation + guidelines in relation to patient records + confidentiality

Question 1

While an oral health assessment is carried out

Answer 1

+ a trt plan is being formulated for the pt, nurse will be recording various findings + points made in the pt records.

Question 2

The purpose of dental records

Answer 2

to provide up to date case history of each pts condition, + includes exam findings + trt given on each attendance.By referring back to previous visits, dentist can assess results of earlier COT + decide best line of trt on future occasions

Question 3

Adequate records

Answer 3

also facilitate transfer of pts between dentists when absence occurs.
when recorded correctly, another dentist should be able to determine all previous trt + continues that care safely, without risk of errors or omissions due to incomplete info

Question 4

The completeness + accuracy of records is required for:

Answer 4

patient safety, evaluation of trt, basis for pt accounts, monitoring of the provision of care, probity enquiries

Question 5

Patient records essentially consist of personal + clinical info including:

Answer 5

• Pt name, address, DOB, telephone number
• Doctor’s details + contact info
• full medical history, dental history
• contemporaneous clinical notes of each attendance (i.e written at the time or asap afterwards so in date order)
• tooth + periodontal chartings
• soft tissue assessments
• details of all appts with other staff such as hygienist, therapist or OH educator

Question 6

Patient records essentially consist of personal + clinical info including:

Answer 6

• all legally required NHS or private paperwork
• consent forms
• copies of all referral letters + response correspondence
• correctly identified + mounted radiographs
• photographs
• lab slips
• records of all payment transactions
• copies of all pt correspondence
• info on failed or cancelled appts

Question 7

Pts with same name or dob

Answer 7

the record should be clearly marked to alert all readers as there is a risk of one pt will receive trt required by another

Question 8

New pts

Answer 8

the personal details, reason for attendance + medical/dental history are all recorded by giving or sending medical history form (e.g British Dental Association BDA Confidential Medical History Form) for completion before visit

Question 9

At that visit

Answer 9

would be assessed by dentist, signed + dated + placed in pt’s file.
clinical details of the visit + subsequent ones are entered on dental chart + kept in the file