An assessment of oral health status consists of both an extra-oral assessment (head and neck), intra-oral assessment of the oral mucosal tissue, periodontal tissues, teeth and dentures (if present).
Clinical records are a chronological history of the assessment and care of patients, and therefore it is important to record details of each element of the patient assessment so that a permanent record is produced. This will enable the provision of quality patient care and help in any medico-legal situation.
The SDCEP Oral Health Assessment and Review: Guidance in Brief [1] provides further advice on conducting patient assessments and the information to record, including example recording forms (see also under Templates).
Record details of each element of the patient assessment, including all relevant information about any significant findings and where there are no significant findings
Keep any radiographs taken and radiographic reports of each radiograph as part of the patient’s record. Note that recording and documentation of radiographs are covered by the Ionising Radiation Regulations 2017 [2] and Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R) [3] (see Radiation Protection).
Record details of any other tests or investigations carried out.
Following assessment of the patient’s oral health status, document any diagnoses made.
Keep copies of any referral letters. You should explain to the patient the circumstances in which their information will be shared e.g. referral to a specialist. The patient should have the opportunity to refuse.
Record whether consent has been given or not. For consent to be valid the patient should be aware what information will be released and why, who it will be released to and the likely consequences. If the patient refuses, this should be respected unless there is an overriding public interest (see Obtaining consent).
Record details of the agreed care plan for each patient, including any preventive or operative treatments and their costs, advice for the patient, any referrals, the recall interval and the date the plan was agreed. Provide the patient with a copy.
NB: It is also advisable that the patient and practitioner sign the agreed care plan. (see Communication for further details about discussing care with patients).
Record in the patient’s notes the date and name of the practitioner who carried out the examination or test.
Sources of information
- Oral Health Assessment and Review. Scottish Dental Clinical Effectiveness Programme (2011)
- Ionising Radiation Regulations 2017
- The Ionising Radiation (Medical Exposure) Regulations 2017
Templates
- The following example forms (pdf) for recording a patient’s oral health status are provided with SDCEP’s Oral Health Assessment and Review: Guidance in Brief
- Assessment of Dentures
- Assessment of Head and Neck
- Assessment of Oral Mucosal Tissue
- Assessment of Teeth
- Basic Periodontal Examination and Dentition Care Requirements
- Radiographic Assessment