Record keeping
General principles of record keeping
Good record keeping underpins the provision of quality patient care. Increasingly, the care of patients is shared among dental team members and between other professionals. Therefore, it is important to practise good record keeping to ensure that all relevant information is available to facilitate the provision of effective, long-term shared care of patients. If records are completed accurately, they will provide a long term record of the care provided for all of the dental team to access and which is essential for medico-legal reasons.
Ensure all records are:
- specific to the patient;
- accurate;
- dated;
- confidential;
- secure;
- contemporaneous (recorded at each appointment);
- comprehensive (note which elements of assessment and treatment have been completed at a given appointment; include positive results and any concerns of the patient or clinician);
- written in language that can be understood by others to enable effective shared care.
N.B. Using computerised systems avoids problems with legibility. However, if notes are handwritten, ensure that they can be read and understood by others.
Do not remove or edit any entries from records.
Ensure patient data are recorded, processed and stored in accordance with the General Data Protection Regulations (GDPR).
N.B. Patients have a right under GDPR to access their dental records.
Information specific to periodontal diseases
A significant number of complaints, claims or referrals to the General Dental Council (GDC) are due to allegations of undiagnosed and inappropriately managed periodontitis. Good record keeping is vital to show that each patient has received regular periodontal screening and, where necessary, the further charting, advice, treatment and monitoring appropriate to their level of disease.
The patient’s clinical notes should record the diagnosis and classification and any risk factors for periodontal disease that have been identified, as well as more general aspects such as medical and previous dental histories. A treatment plan, with details of necessary active treatment rather than only periodontal maintenance, is also part of the patient’s medico-legal record and it is important that it is individualised and specific to each patient.
Records should include any discussions you have with a patient regarding the nature and extent of their periodontal disease, the significance of risk factors which complicate disease when present, treatment options and likely outcomes. It is also important to gauge the level of understanding of the patient and adjust your communication style and method to suit them.
For each patient, record:
- personal details;
- dental history, including previous dental experience, oral hygiene habits and previous periodontal treatment;
- medical history, including details of any medications (contact the patient’s general medical practitioner if clarification is required) and systemic conditions which may be relevant to periodontal diseases (e.g. diabetes);
- social history, including smoking status, alcohol consumption and any details of a family history of periodontal disease.
At each recall appointment, ensure that all details of the patient’s history are up to date.
Record any specific complaints that the patient may have regarding their periodontal health, for example, gums which bleed on brushing or interdental cleaning or teeth which feel loose. Note whether these issues are recent or are recurrent.
Record the patient’s self-reported oral hygiene habits.
Record the results of the Basic Periodontal Examination and the standard of oral hygiene.
N.B. If the patient has a BPE score of 3 or 4 or already has a diagnosis of periodontitis, further examination is required.
For patients who require further periodontal examination (see Full periodontal examination), record probing depths and presence or absence of bleeding on probing from the base of the pocket. Consider also recording:
- gingival recession;
- details of any furcation involvement;
- tooth mobility;
- plaque and gingivitis charts or indices.
N.B. All of these parameters should be recorded at baseline when an initial diagnosis of periodontitis is made. Annual review charting is required for all patients with a diagnosis of periodontitis, including those who are stable and have shallow pockets.
Record in the notes any provisional diagnosis and follow up with a definitive diagnostic statement once any special investigations have been performed.
Keep any radiographs taken as part of the patient’s record. Ensure that these are justified, authorised and clinically evaluated, with the findings documented in the patient’s notes.
Record the suggested treatment plan and details of costs.
Document discussion of the options, risks and benefits of treatment, including the ‘no treatment’ option. If treatment is declined, record this in the notes.
Record the details of discussions or treatment carried out, including oral hygiene advice and instruction. Record any discussions on smoking cessation, diabetes control, alcohol consumption or other lifestyle factors.
Record details of referrals, including a copy of the referral letter and any response from the referral centre.
Note in the clinical records the appropriate recall period.
Where appropriate, record compliance with advice, for example, oral hygiene instruction or smoking cessation advice.