Ensure your computerised record systems are password protected and include a full audit trail facility that prevents data from being tampered with.
Have in place a system that enables identification of the user, e.g. the dental team member who carries out the examination or treatment and, ideally, the team member who enters the appointment data should log all data entries using individually allocated passwords.
Ensure that dental computer software systems complies with the principles detailed by the Data Protection Act 2018 [1] (see Ethical Practice) and that appropriate software protection (e.g. virus and firewall) is in place and updated frequently.
Confirm with your software provider that your electronic patient records cannot be erased or modified without such changes being recorded.
Put in place a system to protect electronic patient records against loss or corruption of data by:
- making back-up copies of data on a regular, at least daily, basis and storing this information off-site
- making more substantial back-ups of the hard disk weekly and storing this information off-site
- verifying back-ups to ensure they would be fully operational if ever required (obtain advice from your software supplier)
- ensuring multiple staff members know the storage location for back-ups.
- document the protocol for making back-up copies of records.
Ensure that historical data can be retrieved regardless of any future changes in electronic technology.
As patients are entitled to have access to their records, avoid using any derogatory comments about the patient. Personal comments should be avoided.
Use abbreviations that are consistent and understood by all users.
Ensure records are complete, clear, accurate and legible.