To fulfil their primary purpose of supporting patient care, your records should include:
- histories (medical, dental and social)
- dental charting
- findings on examination, including negative findings (eg no teeth tender to percussion)
- 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 keeping good clinical records has more information.
This page was correct at publication on 21/01/2022. Any guidance 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.