Specific points relevant to the record-keeping required for child patients are provided below. For more information on providing care for child patients, see the SDCEP guidance Prevention and Management of Dental Caries in Children. For further details about child protection see Ethical Practice.
For each child patient, record information as detailed in the Patient Histories, Routine Assessment of Oral Health Status and Treatment sections.
Record if appointments were attended, cancelled or if the child was not brought.
Record the deprivation level where the child resides (via Scottish Index of Multiple Deprivation (SIMD)) and date of birth/age for payment purposes to facilitate the provision of preventive care).
Where there is a mixed dentition, clearly record whether the teeth being assessed are the primary or permanent dentition.
In the interests of child protection, record:
- who accompanied the child and, if not the parent, their relationship to the child
- observations of behaviour, not only physical signs
- a summary of any discussions with the child and parent/carer.
If non-accidental injury is suspected during any element of the assessment of child patients, record:
- observations and reasons given for seemingly trivial injuries, which might, over a period of time, show a repeating pattern of injury
- diagrams in addition to written descriptions or clinical photographs ( with consent), labelled with the childs name and date taken
- observations in a way that will be understandable to colleagues so that, even if no single team member gets to know the child, a written record builds up over time
- any differences between the facts (i.e. observations and reasons given by the child and/or parent/carer) and your opinion
Record the categorisation of the child’s caries risk, and the factors on which this is based (e.g. presence of caries, previous extractions, and dietary and oral hygiene factors).
Record details of measures taken to address any problems identified, including preventive programmes, and, as for adult patients, record details of the care plan.
Sources of Information
- Prevention and Management of Dental Caries in Children: Dental Clinical Guidance. Scottish Dental Clinical Effectiveness Programme 2nd edition (2018)
- Scottish Index of Multiple Deprivation. Scottish Government
- Child Protection and the Dental Team: An Introduction to Safeguarding Children in Dental Practice. Department of Health (2009)