If a report clearly and logically describes your total involvement with the patient, you're less likely to be called on to have your evidence tested in court.
What should the report include?
You should include the following points, as appropriate:
- the patient's complaints on presentation
- the patient's histories (medical, dental and social)
- examination findings, including any special tests
- diagnosis and treatment plan
- advice and options given to the patient
- treatment provided, including any mishaps or complications
- details of costs
- any further treatment proposed and the cost.
It's also important to include negative findings. Give the details of what you examined for but did not find.
Factual evidence
- Your report must be based on first-hand evidence. The emphasis must be on your findings or discussions with the patient, rather than on their history.
- Do not give your opinion on the care and treatment provided but give a factual account of the advice and treatment that was provided to the patient.
- Include the nature of your professional relationship with the patient - for example, private or NHS, clinical or forensic, or a combination of both.
- The report should specify which details are based on memory, which are based on contemporaneous notes, and which describe your 'usual practice'. Just give the relevant information; it's not necessary to reproduce the clinical notes of every consultation.
- State whether the patient was seen alone or accompanied by someone else during each consultation. Give the name and status of the other person.
Attention to detail
- Be as thorough as possible. Include all your relevant personal information and background details to the report. List all documents used or relied on. If a drug is mentioned, say what type it is (eg, antibiotic, analgesic) and give its full generic name, dosage and route of administration.
- Write in the first person. The reader needs to be clear about who did what, why, when, to whom, and how you know what occurred. Use the active voice; ie, "I examined the patient," rather than "The patient was examined".
- Avoid abbreviations. Don't assume the reader has any background knowledge of the case, or even of dentistry.
Avoid using jargon, as your report will almost certainly be read by people who are not dental professionals. If you have to use jargon or technical terms, explain it used so non-dentists will understand them.
Check your report carefully before you send it.
Be professional
- Unless you are under a court order, make sure you have obtained the patient's consent when providing a report or disclosing their notes.
- Your report should not be hand-written. Use a headed document, with your full name, professional dental qualifications, postal address and work telephone number.
- State who requested the report, naming the individual or organisation concerned.
- Take care not to breach the confidentiality of third parties.
- Send the report securely. For example, by encrypted email or special delivery post.
This page was correct at publication on 15/03/2022. 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.