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GDC standards Q&A - Principle 4 - Maintain and protect patients' information

Post date: 22/08/2017 | Time to read article: 3 mins

The information within this article was correct at the time of publishing. Last updated 25/10/2019

Do I need to update the patient’s medical history on every appointment?

It is a matter of clinical judgement in the circumstances of each individual case, how often the updating of the patient’s medical history should take the form of a further written questionnaire, or whether it is sufficient for it to be done verbally.

If the latter, the discussion should in any event be confirmed by means of a dated entry in the clinical records. A compromise solution would be a supplementary sheet, or even a rubber stamp on the reverse of the original medical history form, to the effect that the patient has read the previous responses to the medical history questionnaire, and confirms that this information is still correct. This should again be signed and dated by the patient. 

What does contemporaneous mean?

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.

I am told that my handwriting is difficult to read but I don’t like using a computer. Does it matter if I continue to keep paper records?

You may continue to keep paper records but they will need to be legible to any reader. Changing to computer records will solve the problem of legibility, but you could also consider training your dental nurse to write up the records if you really do wish to continue with record cards.

What is best practice encryption for confidential patient communications over the internet?

Dental Protection is seeking clarification from the GDC as to their expectations in respect of sending patient information by email. Encryption will only work satisfactorily if both sender and recipient use the same encryption.

Password protection is an alternative, but relies on the original information and the password being sent to the same email address. If the email address is incorrect in the first instance the password will also go to the incorrect address.

Even posting patient information by special delivery cannot be considered entirely secure. Where possible you should try to remove sensitive patient information from communications between third parties. However Dental Protection will require some patient information, such as name and date of birth, in the initial correspondence, in order to be able to provide the most appropriate advice. On-going correspondence may be dealt with by the use of case reference numbers and patient initials. Please review this page for updated advice as it becomes available.

When I am looking to purchase dental practice software, what risk management functionality do I need to look for?

From a risk management perspective, you should look for ease of printing all relevant patient record information, ideally with a single click. Many current computer systems do not easily print out the whole record. It is also important to be able to print out historical information, such as earlier dental charts and periodontal records.

Many systems currently only print out the most recent chart. As well as the accurate chronological reproducibility of the complete patient record you might also want to consider the ability to print out individual patient treatment plan summaries and pricing that can be offered to the patient to sign at the time of the initial examination.

In addition the system needs to back up to a remote site to ensure data can be restored following an unexpected system failure or service interruption.

Can you explain my responsibility to share patient records and information with a third party if an issue of child protection is raised?

If possible you should seek parental consent for the disclosure of any information about a child. If parental consent is not available, as is often the case in this type of situation, it may be appropriate to disclose the information requested on a public interest ground, or in the patient’s best interests.

Each case must be judged on its own merits taking account of local child protection guidance, with which all clinicians should be familiar. If parental consent for disclosure cannot be obtained, for any reason, you should discuss the request with one of our dento-legal advisers via the member helpline.

Can I use my mobile phone to take clinical photos or images of radiographs for my own use or to obtain advice from colleagues?

It is important to ensure that the patient cannot be identified from any image taken, stored on or sent from your mobile phone. This includes the face or parts of the face or other details that will allow a viewer to identify the patient. The GDC expects registrants to obtain consent from their patient when taking such images either with a mobile phone or with a conventional camera.

Can I post patient information on Facebook or Twitter when I am seeking advice from colleagues on the best way to treat a patient?

The new guidance specifically states (para 4.2.3) ‘you must not post any information about patients on social networking or blogging sites’ such as Facebook and Twitter. 

« Principle 3 - Obtain valid consent

Principle 5 - Have a clear and effective complaints procedure »

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