National Institute for Health and Care Excellence. Dental recall: recall interval between routine dental examinations. Clinical guidance 19 (CG19). 2004. https://www.nice.org.uk/guidance/cg19 (accessed August 2022)
Dentists are required to make and keep accurate dental records of care provided to their patients. As such, dentists should familiarize themselves with data protection legislation and how that impacts their practice. This article discusses the benefits of good record keeping, the use of templates in record keeping, access to and retention of dental records and the benefit of audit to ensure record keeping is meeting current standards.
CPD/Clinical Relevance: An update and overview for the dental team on record keeping and the relevant standards.
Article
Good record keeping is not only a GDC requirement,1 but an expectation for the competent professional practice of all healthcare professionals. In general, the benefits of good record keeping are to:
With an increasing focus on dentistry moving towards a more integrated care pathway approach, adopting a more consistent way of recording patient information is key for better information sharing, care planning and patient safety. The 2019 NHS England and NHS Improvement standards,3 which apply to NHS practices only, were agreed between commissioners, regulators and the profession. However, there has been considerable controversy surrounding them because some elements contradict the FGDP/College of Dentistry guidance.4
The standards3 include three separate tables to show what information is considered essential, aspirational, conditional, or not required for recording in patient records for each of the following scenarios:
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