Oral Health | Clinical and Risk Asessment | What should be recorded in clinical notes

What should be recorded in clinical notes
Session overview
Description
This session examines the essential details that should be recorded in a patient's clinical notes for common dental procedures. Good practice guidelines surrounding the retention of patient records are also discussed together with the importance of confidentiality.

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

• describe in detail what constitutes good clinical records
• discuss how much information should be recorded
• identify what is essential and what is 'good practice'
• explain the legislation surrounding the retention of patient records
• demonstrate an understanding of the importance of confidentiality

Prerequisites
Before commencing this session you should:

• complete the e-Den session: Patient assessment/The patient’s profile/The importance of good record keeping
• have a basic knowledge of what constitutes a good patient record and the importance of confidentiality
• be familiar with the Faculty of General Dental Practice's guidance on Clinical Examination and Record Keeping
• be familiar with the General Dental Council's Standards concerning Patient Confidentiality

Many dentists keep medico legally vulnerable patient records. Record keeping is often given little priority, either because the dentist runs short of time or because of a failure to understand how beneficial good patient records are and the pitfalls of poor records. The advent of computer records does not appear to have markedly improved the standard of patient records although they are usually more legible.

Keeping good clinical records is an essential component of good patient care, but it is all too easy to develop bad habits in record keeping, and to only discover how important it is when a patient makes a complaint and there is no evidence to back up what the dentist thinks he or she remembers from the treatment.

Many dentists ask the question, "How much information is enough?" This session looks at the detail required for:

• a new patient examination
• a recall examination
• radiographic reporting
• periodontal therapy
• a filling
• a crown or bridge
• a root filling
• a denture
• an extraction or surgical procedure