How much detail should I include in a patient's records?

22 August 2016

To fulfil its primary purpose of supporting patient care, your record should include:

  • histories (medical, dental and social)
  • dental charting
  • findings on examination, including negative findings (eg no teeth tender to percussion)
  • diagnosis
  • information given to patients, as part of the consent discussion
  • agreed treatment plan and consent
  • treatment given
  • any mishaps and complications
  • the date of each entry
  • the identity of the person making it.

Be aware that telephone consultations, handwritten notes, radiographs and correspondence form part of a patient's dental record; complaints correspondence should be filed separately.

Our guide to clinical records has more information.

This guidance was correct at publication 22/08/2016. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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