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12 record keeping tips

Post date: 30/11/2018 | Time to read article: 2 mins

The information within this article was correct at the time of publishing. Last updated 03/04/2019

Creating good treatment records is a key part of providing optimal patient care – something all healthcare professionals should strive for. These records can include electronic documents, hand-written notes, voice recordings, emails, consent forms, text messages, lab results, photos, videos and printouts.

Record keeping is a topic we talk about a lot at Dental Protection. But there’s a reason for that. Creating good dental records promotes patient care and safety, while also allowing a clinician to easily explain what has happened and what has been discussed – this can be particularly important should a patient ever complain.

At every stage of your career, it’s crucial that you make a record of key conversations with patients and colleagues, any diagnosis and all treatment plans you recommend , details of clinical treatment carried out and any post-operative care and advice that is relevant.

Making a list

  1. All your records need to be clear, accurate and legible.
  2. They should be dated and detailed, and written at the time of the event being recorded or as soon as possible after.
  3. All treatment records should be documented in a standardised structure and layout, and viewable in chronological order to reflect the patient’s care.
  4. Remember that the record may at some later point be read by the patient, their adviser, or anyone else asked to investigate or audit the treatment carried out.
  5. Withholding consent, refusing to undertake or comply with necessary and recommended treatment are rare events, but of such significance, that when they happen they must be very clearly recorded in the patient’s notes.
  6. Altering or amending a patient’s treatment record at a later date may result in it being viewed as less reliable and could make it more difficult to use in the defence of a claim if needed.
  7. Patients have the right to access their treatment records under the data subject access provisions in the General Data Protection Regulations (EU) 2016/679 (GDPR).
  8. Under GDPR a patient can also ask for factual inaccuracies to be changed, but not professional opinion.
  9. General Dental Service records should be retained for a minimum period of 10 years from the date of discharge of the patient or when they were last seen. This is because claims can arise after an extended period of time, dependent upon when the patient becomes aware of the alleged sub-optimal care. Without records, any claim will be much harder to defend.
  10. Before any records are destroyed, they should be reviewed first – and if any have been involved with a complaint or claim, then it’s always best to keep them.
  11. Before filing any record that may have been completed by your dental nurse, check it thoroughly and initial the entry to show you have reviewed it and that it accurately reflects the treatment and discussions that took place.
  12. Failure to process, retain and dispose of data in an appropriate manner will be deemed a breach of GDPR.

If you have any questions or need any further advice on record keeping, please get in touch on 0800 561 1010 or visit dentalprotection.org.

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