It is important to record details of any treatments in the patient’s notes to facilitate the provision of quality patient care and provide a permanent record for reference.
For any treatment carried out, record in the clinical record:
- the date of treatment
- what is being treated
- the type of treatment being carried out and the reason based on the diagnosis
- any tests carried out
- the materials used
- discussion of the options, risks and benefits of treatment, including the ‘do nothing’ option;
- advice given to the patient either verbally, in written form or by phone
- the patient’s consent (see Communication for more details about the principles of obtaining consent)
- the patient’s refusal of treatment or advice
- any concerns of the patient and/or the dental team
- any medication provided (see below), and any adverse reaction
- changes to the treatment plan
- results of the treatment (prognosis)
- the name of the practitioner.
If any drugs are used (e.g. anaesthetics or analgesics), record the drug used, including its generic name and concentration (and whether another agent is present), and the dose administered.
Record the batch numbers of drugs and materials used.