Record keeping

Dental records and the law

For a brief summary of the dento-legal issues associated with record keeping, please see the Annual Review 2007; On the record. (page 32)

Dental Protection is very grateful for the advice of David Kan and the legal team at Richards Butler in the preparation of this guidance to support the information on page 32 and 33 of the Annual Review 2007.

Because individual situations will vary, this information is provided for general guidance only. Regardless of any specific legal requirement it is best practice to keep all your dental records for as long as possible.

If you require more specific information on a particular issue relating to dental record keeping please click here to contact us.

Q. Is there any legal requirement which determines the length of time that a dentist needs to keep their patient’s clinical records in Hong Kong?

A. Paragraph 5 of the Code of Professional Discipline for the Guidance of Dental Practitioners published by the Dental Council of Hong Kong provides as follows:

"Dental Practitioners should keep accurate and contemporaneous records of dental treatment and should keep them for a minimum of three years since the patient's last treatment. It is the responsibility of the dental practitioners to safely maintain these records against loss and to safeguard their confidentiality." [our emphasis]

In Hong Kong, the provisions on the limitation period are similar to the UK provisions. In summary, a patient/claimant is required to issue legal proceedings within the limitation period, calculated as three years from the date of the alleged negligent incident, or three years from the date when the patient acquired the relevant knowledge regarding the alleged negligence. The Dental Council has probably taken into account these provisions regarding the limitation period in recommending that records should be kept for a minimum of three years.

Q. Are there any legal obligations about the storage of dental records?

A. Please refer to paragraph 5 of the Code above.

The Data Protection Principle 4 of the Personal Data Privacy Ordinance is also relevant. In summary, records of personal data should be stored safely so as to prevent against unauthorised access, copying, deletion, loss and to safeguard their confidentiality.

Dental records may be stored as hard copies or in the electronic form. In respect of the latter, the Privacy Commissioner has recommended that there should be adequate security features including appropriate hardware, software, encryption and administrative measures to prevent unauthorised access to and disclosure of data in the database and to preserve data confidentiality and accuracy.

Q. Are there any legal requirements about disposal of either paper or computer-held records?

A. Care should be taken in disposing records so as to ensure that there is no breach of confidentiality of the patient's data.

Q. Under what circumstances does a dentist have an obligation to disclose their records and if so, who might be authorised to request that disclosure? In addition does the patient have a right to have a copy of their record and if so what conditions might apply to such a request (eg. speed of response to the request/ charge to patient)?

A. We attach a copy of Sections 18 and 19 of the Personal Data Privacy Ordinance. In summary, upon receipt of a written request from a patient, a dentist is obliged to disclose a copy the patient's medical records within 40 days, unless doing so would be likely to cause serious harm to the physical or mental health of the patient or any other individuals. A dentist is entitled to charge a reasonable fee for providing the records.

Q. Are there any observations about clinical records that you feel might help our members?

Dentists should remember that:

  • Besides clinical notes, there are other types of records, including radiographs, treatment photographs, dental casts etc.
  • Records should be contemporaneous - a dentist should not alter records after the event. If he wishes to make additions to the records, he should keep a separate addendum instead of altering the original records.
  • It is important to record information such as informed consent as well as negative findings etc.
  • On the question of how much information should be records - the test is whether it is sufficient to assist the dentist in reconstructing the relevant events without relying on memory.

Dental Protection Limited (registered in England No. 2374160) is a wholly owned subsidiary of The Medical Protection Society Limited (MPS) which is registered in England (No.36142). Both companies have their registered office at 33 Cavendish Square, London W1G 0PS.

 

‘DPL membership’, ‘DPL member’, ‘Dental Member’ and ‘Dental Protection member’ refer to a dental member of MPS. Dental Protection Limited serves and supports the dental members of MPS, with access to the full range of benefits of membership which are all discretionary and set out in MPS’s Memorandum and Articles of Association. MPS is not an insurance company. 

 

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