Record keeping

They serve as an important reminder to the clinician who has consulted with the patient, and also provide important information to others sharing that patient’s care. It is important for a record to be adequate and include key points such as history and examination, relevant clinical findings, the decisions made and actions agreed, including the advice or information given. Dental records may also be required for legal purRecord keeping for dentists session 1poses and are essential in defending negligence claims.

The risk team have identified the following key tools from our resources to help you work through this common area of risk:

• Online course: Good practice in record keeping for GDPs. This 45-minute course details key dento-legal requirements and sets out the legal framework associated with record keeping. It also highlights common pitfalls and explores professional guidelines and good practice in this area. On completion of the final assessment, you can print or save a certificate for your CPD portfolio.
• Checklist: Dental records management. This updated checklist is intended to act as both a health check and basic risk assessment on the systems and processes in place to safely and securely manage the dental records of existing, new and former patients in the practice.
• Checklist: Clinical dental record keeping. This updated checklist is intended to act as both a health check and basic risk assessment on compliance with the various dental professional and regulatory standards and guidance on clinical record keeping.
• Article: Altering patient records. Clinical notes are an important record of the encounters between dental staff and their patients. Altering them in a less than honest or straightforward way can result in serious consequences. This risk alert explores some of the common pitfalls.
• Article: Keeping safeguarding records safe. Safeguarding potentially vulnerable children can pose particular challenges to dentists - and the processing and storage of records and case conference reports is a frequent issue. This risk alert explores some of the important aspects of safe records management.
• Quiz - record keeping. Click to test your knowledge on record keeping.
• Webinar: Record keeping for dentists - session 1. This one hour webinar includes relevant information regarding what you must do in record keeping.
• Webinar: Record keeping for dentists - session 2. Session two of this webinar series explores how to obtain valid consent and ensure your records demonstrate this.