Record keeping

Good dental records can ensure that patients receive continuity of care.

They serve as an important reminder to the clinician who has consulted with the patient, and also provide important information to others sharing that patient’s care. It is important for a record to be adequate and include key points such as history and examination, relevant clinical findings, the decisions made and actions agreed, including the advice or information given. Dental records may also be required for legal purposes and are essential in defending negligence claims.

The risk team have identified the following key tools from our resources to help you work through this common area of risk:

  • Online course: Good practice in record keeping for GDPs. This 45-minute course details key dento-legal requirements and sets out the legal framework associated with record keeping. It also highlights common pitfalls and explores professional guidelines and good practice in this area. On completion of the final assessment, you can print or save a certificate for your CPD portfolio.
  • Video: Principles of good record keeping in dentistry. Mr Aubrey Craig, head of dental division with MDDUS, discusses the importance of good record keeping in the light of revised and extended guidance for dentists from the General Dental Council.
  • Article: How's your record keeping? Dr Terry Simpson champions an audit tool for assessing the quality of dental records.
  • Article: On the record. As dentists face rising numbers of patient complaints, clear and accurate dental records have never been so important.
  • Video presentation: Records management. Watch MDDUS risk adviser Alan Frame as he explores both the clinical and legal reasons for maintaining good patient records, and how these can be invaluable in assisting clinicians where standards of care have been called into question.
  • Checklist: Dental records management. This practical checklist will assist dental practices in ensuring they have robust systems in and processes in place to manage their patient records.
  • Checklist: Clinical dental record keeping. Dentists and practice managers can use this checklist to review practice processes in areas such as viewing and actioning patient results and other hospital correspondence.
  • Video: An introduction to practice risks in dentistry. This documentary examines common risk areas including record keeping within a busy imaginary dental practice. The film is aimed primarily at vocational trainees and newly qualified dentists, and can also be used as an educational aid for practice teams using the accompanying ‘Discussion Guide’
  • Blog: Records – friend or foe? This blog will further help you reflect on how your clinical records might stand up to scrutiny by the regulators.
  • Article: Altering patient records. Clinical notes are an important record of the encounters between dental staff and their patients. Altering them in a less than honest or straightforward way can result in serious consequences. This risk alert explores some of the common pitfalls.
  • Article: Keeping safeguarding records safe. Safeguarding potentially vulnerable children can pose particular challenges to dentists - and the processing and storage of records and case conference reports is a frequent issue. This risk alert explores some of the important aspects of safe records management.

GP risk toolbox

MDDUS risk toolboxes are designed to help GPs and practice managers review key risk areas within their practice