Making a list and checking it twice – the things to remember when it comes to making and retaining good patient records

New data protection regulations came into force on 25 May and MPS is committed to fulfilling its legal obligations – correct redaction and anonymisation is one way that you can play your part in safeguarding data.

We look at how the new General Data Protection Regulations (GDPR) impact your dental practice.

Useful information for preparing for new GDPR

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

Dental professionals are required to make and keep accurate dental records of care provided to patients, whether NHS or private. Dental Protection is frequently contacted by members who want to understand how long records should be retained by the practice.

Dental professionals are required to make and keep accurate dental records of care provided to patients, whether NHS or private. Dental Protection is frequently contacted by members who want to understand how long records should be retained by the practice.

Dental professionals are required to make and keep accurate dental records of care provided to patients, whether NHS or private. Dental Protection is frequently contacted by members who want to understand how long records should be retained by the practice.

Like their medical counterparts, Dental Boards and Dental Councils around the world have been wrestling with this issue for some years now. Most regulatory bodies consider that when giving advice remotely in relation to the treatment of a specific patient, you are practising dentistry, even if you never actually meet the patient in person.

John Tiernan, Director of Educational Services at Dental Protection explains the importance of the original patient record when your clinical skills face a legal challenge and emphasises the consequences if a dental professional changes a clinical record in an attempt to cover up a mistake.

Patients are often prompted to visit the dentist because they have been experiencing pain or discomfort.

There is never a bad time to review the way that you keep records of dental patient treatment.

A clinician’s specialised knowledge of the aetiology of various oral and dental conditions places him, or her, in a position of significant advantage relative to most patients.

One of the advantages of keeping careful and detailed records of a patient’s pain history is that it highlights significant changes and developments in the features of the patient’s symptoms which can, in turn, lead the clinician to the correct diagnosis.

In case after case, the question arises of what information a patient was given in advance of their treatment. Obviously, this is material to the quality of the consent obtained from the patient, and yet dentists, hygienists and therapists often find themselves unable to demonstrate with any certainty, exactly what the patient was told, when, and in what terms.