Follow the four Cs
Good patient records follow the four Cs:
Records should be made at, or very close to, the time of the examination, treatment, observation or discussion, and they should be dated and signed legibly.
They should be written carefully, so that they can be understood by anyone who may need to read and interpret them.
Records should be just long enough to convey the essential information.
All aspects of a patient's visit should be recorded. This includes:
- histories (medical, dental and social)
- presenting complaints dental charting
- findings on examination, including negative findings (eg soft tissues nothing abnormal)
- special tests
- discussions about treatment options and risks
- agreed treatment plan
- details of the consent process
- treatment given
- mishaps and complications.
Request forms, such as those for pathology reports or radiographs, should be completed clearly with adequate detail, dated and signed legibly.
All reports should be seen, evaluated and initialled before being filed, with any abnormal results noted in the clinical record and any action recorded.
Be clear and consistent
- Avoid abbreviations as far as possible. They may be misunderstood or misinterpreted.
- Make sure your handwriting and signature are legible.
- Use one recognised system of dental charting (Palmer notification, FDI notation or another) consistently throughout the records.
- Check dictated and typed notes, or notes made by somebody else on your behalf, such as notes 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.
- Notes, including any amendments or contributions from others, should be dated and signed legibly.
- Evaluate and initial any contributions from third parties before filing them.
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 electronic records so that 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 the use of strong passwords and data encryption.
- 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. The Department of Health has said that 'the movement of unencrypted data held in electronic format should not be allowed in the NHS' and 'wherever possible, person identifiable data should always be stored on a secure server'.
- 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 person in charge of data security. Follow practice or trust procedures, for example on the use of laptops and portable data storage.
This guidance was correct at publication 22/01/2018. 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.