18 September 2014
When referring to clinical records it means records made at the time the patient is treated. Records made contemporaneously will be more accurate, as there is less likelihood of something being forgotten or incorrectly recalled.
If made at the time of treatment, there is no risk that the records can be influenced by subsequent events, such as the patient making a complaint to the receptionist after treatment has been completed. Dental Protection interprets the time of treatment as the period whilst the patient is seated in the dental chair for a consultation, as well as when specific treatment is being provided.
Records made at the end of a session, or at the end of the day, are not considered to be contemporaneous. Working in a busy practice is not an acceptable reason for a delay in writing the records.