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Records Required


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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.