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20 August 2018
Automatic templates are drawn up by some practices to make it quicker and easier for dentists to record the routine advice they provide to patients after certain treatments.
However, using templates to record information in patient notes can also lead to an inaccurate account of what happened at an appointment. Examples include:
Similarly, identical entries in every record (eg 'examination, medical history checked, bp recorded' at the start of every entry or 'patient understood/agreed/happy' at the end of every entry) can make it difficult to justify what information was actually provided to a patient if a complaint or claim later arises.
Automatic templates should also not be entered into a record in advance of a future appointment, for example as anticipation of what the dentist is planning to provide as part of the patient's treatment plan.
While the use of automatic templates from drop-down menus is not in itself wrong, for safer patient care you should bear in mind the following:
When completing patient records, whether electronic or manual, make sure:
For dento-legal purposes, computer software should be capable of producing hard copies of records and radiographs, and of producing a full audit trail of record creation and modification.
See our guide to computer-held records for more information.
This guidance was correct at publication 20/08/2018. 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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