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Children’s Assessment

hands resting on a pile of records When assessing child patients, it is important to record information as detailed in the Patient Histories, Routine Assessment of Oral Health Status and Treatment sections.

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.

Consider the questions in the BDA Child Protection and SDCEP Caries in Children resources while undertaking examinations and treatment,  to ascertain if a child protection referral may be required.