In this section:
- Patient Histories
- Routine Assessment of Oral Health Status
- Children’s Assessment
- Emergency Patient Assessment (unscheduled visit)
Patient records must be comprehensive and include personal details, dental history, social history and medical history and the clinical examination of each patient.
Maintaining comprehensive and up-to-date records enables the provision of quality care that is safe, addresses the specific needs of individual patients, facilitates effective shared care and provides a permanent record of the care of patients, which might prove useful in the event of complaints or for medico-legal reasons.
The SDCEP Oral Health Assessment and Review: Guidance in Brief, provides advice on conducting patient assessments and the information to record, including example recording forms.