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Inaccurate dental charting in an audit of 1128 general dental practice records Nathan L Brown Victoria EL Jephcote James N Morrison Jessye E Sutton Dental Update 2024 44:3, 707-709.
Authors
Nathan LBrown
BDS, MFDS RCPS, PhD, MSc, DipFMS, DipFHID
GDP and Forensic Odontologist, Apple Dental Practice, 43A Abbotswood, Yate, Bristol, BS37 4NG
Fourteen dentists at different practices in the UK assessed the dental charts of 1128 patients who were new to the dentist but not new to the practice; 44% of the dental charts were found to be inaccurate. Inaccuracy of the individual practice-based charts ranged between 16% for the best performing practices to 83% for the worst: 5% of dental charts had too many teeth charted and 5% had too few teeth charted; 13% of charts had missed amalgam restorations and 18% had missed tooth-coloured restorations; 5% of charts had amalgam restorations recorded but with the surfaces incorrect (eg an MO restoration charted but a DO restoration actually present); 9% of charts had tooth-coloured restoration surfaces incorrectly recorded. For 7.5% of charts, amalgams were charted but not actually present. Other inaccuracies were also noted. The authors reinforce the requirements of the GDC, the advice of defence organizations, and the forensic importance of accurate dental charts.
CPD/Clinical Relevance: Dental charting forms part of the patient's dental records, and the GDC requires dentists to maintain complete and accurate dental records.
Article
It is in the interest of the general dental practitioner to maintain good dental records in order, not only to best serve their patients, but also to protect themselves. A raft of recommendations and legislation exists reinforcing the need for good dental records.
In the UK, the General Dental Council (GDC) requires dental professionals to make and keep accurate and complete patient records. Principle 4 of the standards for the dental team document1 which covers maintaining and protecting patients' information says registrants must make and keep contemporaneous, complete and accurate patient records each time a patient is treated, and this is compulsory. Dental records include not only dental notes and charts, but also radiographs, consent forms, photographs, models, audio and visual recordings of consultations, laboratory prescriptions, statements of conformity and referral letters. The GDC also states that registrants must ensure that all documentation that records a dental practitioner's work is clear, legible, accurate, and can be readily understood by others. Other legislation covering dental records includes the Data Protection Act, 1998.2 Principle 4 states that ‘personal data (such as name, date of birth and address) shall be accurate, and where necessary kept up to date’. The Care Quality Commission (CQC) in England expects records to be accurate and fit for purpose in accordance with regulation 17 of the Health and Social Care Act 2008 (regulated activities) 2014.3 Other legislation relating to record-keeping includes The Consumer Protection Act 1987, the Medical Devices Directive (Directive 93/42/EEC), the Medicines Act 1968 and the Misuse of Drugs Regulations 2001. Also, the NHS has its own guidance in the NHS Code of Practice.4
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