23 January 2012
Last updated 
On this page:
In the context of CQC compliance records mean both clinical records detailing patient care as well as records relating to the management of the practice including employment records and health and safety documentation. These are “business records”
A dental record is any record that contains information relating to the physical or dental health or condition of an individual and has been made by or on behalf of a dental professional in connection with the dental treatment of that patient. In this context, dental records can therefore cover a wide range of material including:
- Dental, medical or social histories
- Clinical data
- Study casts
- Radiographs
- Laboratory instructions and medical devices statements
- Correspondence with hospitals and specialists
- Results of special investigations
- Copies of correspondence between the dentist and the patient
A business record may be defined as recorded information in any form, created or received in association with the normal activities of running the business, and kept as evidence of such activity.
Regulation
Click here to read what the The Health & Social Care Act 2008 (Regulated Activities) Regulations 2009 state.
Top
Guidance
The CQC Guidance about compliance : Essential Standards of Quality and Safety is designed to help providers comply with the Regulations.
CQC will use this guidance to decide whether to register a provider, and also when monitoring the service after registration. CQC has produced guidance for providers about what kind of evidence can be used to demonstrate that the outcomes described in the Essential Standards of Quality and Safety document are being met: Using evidence of outcomes to demonstrate compliance
Top
Outcome
This is what the CQC expects people using a service will experience when the provider is meeting the essential standards
What should people who use services experience?
People who use services can be confident that:
- Their personal records including medical records are accurate, fit for purpose, held securely and remain confidential.
- Other records required to be kept to protect their safety and wellbeing are maintained and held securely where required.
This is because providers who comply with the regulations will:
- Keep accurate personalised care, treatment and support records secure and confidential for each person who uses the service.
- Keep those records for the correct amount of time.
- Keep any other records the Care Quality Commission asks them to in relation to the management of the regulated activity.
- Store records in a secure, accessible way that allows them to be located quickly.
- Securely destroy records taking into account any relevant retention schedules.
Top
Prompts
CQC Prompts for all providers to consider
Top
Compliance
When completing an application for registration a provider must declare compliance or non-compliance with each Regulation, eg, Regulation 21 : Records. For obvious reasons it is important that the information in the application is true and accurate.
If a provider is non-compliant this must be declared and at the same time a compliance plan must be submitted with details of how the provider will become compliant and the timescale.
A provider who demonstrates insight in identifying and declaring non-compliance and submitting an appropriate compliance plan is likely to be in a better position than a provider who declares compliance and is later found not to be in a position to demonstrate compliance.
Using evidence of outcomes to demonstrate compliance
When CQC monitors your compliance with the essential standards, it will check that you are meeting these outcomes. CQC will focus on evidence which demonstrates that people who use services:
- Have good outcomes and experiences, meaning that their care is effective and that they are safe.
- Are involved in their care and that their views are listened to and acted on.
By focusing on outcomes rather than looking only at a provider’s policies and procedures, CQC states that it can assess health and social care services in a way that is centred on people who use services. This means actually considering the effect that a service has on people.
You may wish to consider:
- Record keeping protocols and team training in relation to this
- Record card audits and any subsequent improvements introduced as a result
- Information conveyed to patients about their records including access and confidentiality.
- Storage of records
For example, you could use evidence directly from people who use services and those acting on their behalf, such as:
- Surveys of people who use services, their carers and families.
- Complaints and feedback from people who use services.
- Patient reported outcome measures (PROMs).
- Feedback from other sources eg local groups.
Many dentists are used to collecting feedback from patients. In reality patient feedback is a valuable practice development tool. It collects the views and opinions of patients and service users on the care they have experienced. There are different ways of collecting feedback including the use of anonymous feedback forms, comments books, audits, complaints and compliments. Some practitioners have also used, one-to-one interviews and focus groups.
CQC will take note of patient views as they are the service users. In order to capture this information with regards to patient records you may wish to include a question on this in any patient survey you carry out or in any feedback you collect, eg, were you advised how you can access your records?
Once you have collected the feedback you need to review it and decide how to use it to continue to develop your practice. A useful next step is to then inform patients of how their feedback has been used and what changes have been made. This could be done in the practice newsletter or by way of information in the waiting room. In this way patients feel more involved in the practice.
Top
Resources
Available from CQC
CQC refers to the following documents in Appendix B
- The NHS Constitution (DH, 2009)
- Confidentiality: NHS code of practice (DH, 2003)
- Caldicott Guardian Manual 2006 (DH, 2006)
- Records management: NHS code of practice (DH, 2006)
- Information security management: NHS code of practice (DH, 2007)
- NHS Information Governance: Guidance on Legal and Professional Obligations (DH, 2007)
- Relevant professional guidance and codes of conduct and practice relating to record keeping published by professional bodies and registration councils including the General Medical Council, Nursing & Midwifery Council, General Social Care Council, BMA, RCN, Health Professional Council, Royal College of Physicians and the Academy of Medical Royal Colleges
- DH – Procedures for the Approval of Independent Sector Places for the Termination of Pregnancy
- Codes of practice published by the Information Commissioner
Available from the GDC
Make and keep accurate and complete patient records, including a medical history, at the time you treat them. Make sure that patients have easy access to their records.
Available from Dental Protection
Additional resources
- FGDP(UK) Clinical Examination and Record Keeping: Good Practice Guidelines 2nd edition, published 2009