Good record-keeping underpins the provision of quality patient care. Increasingly, the care of patients is shared among dental team members and between other professionals. Therefore, it is important to practise good record-keeping to ensure all relevant information is available to facilitate the provision of safe, effective, long-term shared care of patients. If carried out consistently for each patient, it will provide a permanent record of the care of patients.
The General Dental Council (GDC) ‘Standards for the dental team’ [1] expects patient records to be complete, contemporaneous, clear, accurate and legible. Records can be held either as a paper copy or digitally on a secured computer.
Note that patient records must be managed according to the Data Protection Act 2018 [2]; this is covered in more detail in Ethical Practice.
Ensure all records are:
- accurate
- dated
- confidential
- secure
- contemporaneous (updated at each patient appointment)
- comprehensive
- legible and written in language that can be read and understood by others to enable effective shared care (using computerised systems avoids problems with legibility).
Use standard forms to record information for consistency and to avoid omissions of any details.
Do not remove any entries from records.
Whether paper or electronic records are kept, have in place a system that enables identification of the patient.
Ensure patient data is recorded and processed in accordance with the Data Protection Act 2018 (DPA) [2] and note that patients have a right under the DPA to access their dental records (see Ethical Practice).
Put in place a policy on the disposal of patient records if the practice were to close. (see Practice Closure: Disposal of Patient Records Policy).