Follow the four Cs

Good patient records follow the four Cs:

Contemporaneous

Records should be made at the time of the examination, treatment, observation or discussion, or as close to it as possible. They should be dated and signed legibly.

Clear

Records should be written carefully, so they can be understood by anyone who might need to read and interpret them. Remember, this might also include patients if they request access to their records.

Concise

Records should be just long enough to convey the essential information.

Complete

All aspects of a patient's visit should be recorded. Including, as appropriate:

personal information such as name, date of birth and address
histories (medical, dental and social)
presenting complaints
dental charting, including indices such as BPE, BEWE, etc.
findings on examination, including negative findings (eg, soft tissues, nothing abnormal)
special tests, including radiographs and their reports
photographs, study models
diagnosis
discussions about treatment options, risks and benefits
agreed treatment plan
details of the consent process
details of treatment provided
complications and adverse outcomes
laboratory prescriptions and statements of manufacture
payment history.

Request forms and prescriptions, such as those for referrals or radiographs, should be completed clearly with adequate detail, dated and signed legibly.

Any reports and referral correspondence should be seen, evaluated and initialled before being scanned or filed, with any any action that is needed, recorded and followed up.

Be factual and consistent

Avoid abbreviations as far as possible. They could be misunderstood or misinterpreted.
Where an organisation uses commonly accepted abbreviations, these should be documented and made available with any disclosure of records.
Use one recognised system of dental charting (Palmer notification, FDI notation or another) consistently throughout the records.
Take care when using templates and ensure accuracy. Pre-populated template can be useful but they can increase the risk of incorrect information being recorded.
Clinical records should be dated. Digital records should record the details of the clinician. Handwritten records should be signed.
Make sure your handwriting and signature are legible if using paper records.

Evaluate

Check dictated and typed clinical notes, including those made by somebody else on your behalf, such as notes written by a dental nurse on behalf of a dentist.
Any errors on paper records should be crossed out with a single line and the correction hand-written alongside the error.

Digital records

For dento-legal purposes, your computer software should be capable of producing a hard copy of records and radiographs.

It also needs to be capable of producing a full audit trail of record creation and modification.

Our advice on computer-held records

Take extra care when completing or modifying digital records to make sure the author is clearly identified.
Every time a new record is created or an existing record is modified, the date must be recorded on the system.
Make sure your IT system is robustly protected against unauthorised or unlawful access, with strong passwords and data encryption and avoid storing patient identifiable data on personal mobile devices. See our guide on protecting patient data.
Use secure methods when sending confidential information, and make sure you have regular backups in place to protect against corruption, damage or destruction of files. A back-up of your electronic files should also be held securely off-site in case of accidental loss.
Avoid storing patient identifiable data on personal mobile devices. Seek appropriate IT advice about data destruction before disposing of computer hardware. Digital data can be difficult to delete completely from a hard drive.
Get to know your workplace information security policy, including the name of the data protection officer and person in charge of data security.
Follow practice or Trust procedures, such as those on using laptops and portable data storage.
General advice on data security can be found at the ICO's website.

Other records

Some information might need to be recorded separately from the clinical record:

documents relating to a patient complaint
requests for the disclosure of records
reports for insurance companies
dento-legal reports
correspondence with solicitors
correspondence with indemnity providers and insurers.

The Faculty of General Dental Practice's Clinical examination and record-keeping offers further advice on the principles and practice of keeping good records.

An introduction to good record-keeping

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