An introduction to good record keeping

Records are an essential part of patient care and can provide evidence if your standard of care is called into question.

Follow the four Cs

Good patient records follow the four Cs:

Contemporaneous

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.

Clear

They should be written carefully, so that they can be understood by anyone who may need to read and interpret them.

Concise

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

Complete

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
  • diagnosis
  • 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.

Evaluate

  • 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.

Electronic 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 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.

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Comments

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SANDRA ELSEY

Can clinical notes be recorded in the password of a Dental Nurse?

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The MDU

Dear Sandra

Notes may be made against the log-in ID of a dental nurse where this is appropriate, for example in the administration, correspondence and communication section of the records system. However, where treatment is being provided, the records should always identify the treating clinician who is normally the author of the notes. Many clinical records systems will allow both the treating clinician and the nurse assisting to log in such that both their initials are shown against the relevant records entry.

I hope this helps

John Makin
Dento-legal adviser

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