Oral Health | Clinical and Risk Asessment | What artefacts constitute clinical records

What artefacts constitute clinical records
Session overview
Description
The clinical record is not restricted to what is written in the clinical notes. This session looks at what also constitutes clinical records and how these can be kept safely for the required period of time. The benefits and drawbacks of computerised systems are also explored.

Learning objectives
By the end of this session you will be able to:

• list the artefacts that also constitute a clinical record
• describe how these might be stored safely
• discuss the relative merits and drawbacks of computerised systems
• identify how to minimise any potential drawbacks of keeping computer records
• evaluate what needs to be kept, for how long and what constitutes safe storage

Prerequisites
Before commencing this session you should:

• complete the e-Den session Patient assessment/The patient’s profile/The importance of good record keeping
• complete the e-Den session Patient assessment/The patient’s profile/What should be recorded in clinical notes
• have a basic knowledge of what constitutes a good patient record
• have a basic knowledge of the General Data Protection Regulation

A patient's clinical record is more than just what is written in the clinical notes. It can also contain a number of artefacts such as:

• radiographs
• photographs
• study models
• diagnostic wax-ups
• correspondence relating to the patient
• laboratory prescriptions
• referral letters
• replies to referral letters

Together with the detailed patient records described in the e-Den session Patient assessment/The patient’s profile/What should be recorded in clinical notes, these also constitute clinical records.

It is therefore important that they are all stored appropriately in a safe place and retained for the required time.