Dental records: what should they contain to be compliant?
17 October 2017
Shilla Talati discusses the importance of accurate and up-to-date dental records and the measures you should follow to remain compliant. This article was originally published in Dental Practice Manager Magazine.
As dental professionals we are required to ensure that our dental records are up to date and contemporaneous for a number of reasons.
This is not only our obligation as a clinician but also it helps in a variety of ways to enhance the patients’ treatment. Accurate clinical records can help to ensure that the patient has the correct treatment and it can also help with diagnosing their oral health in the future, as dental care practitioners will be able to see the documented changes to oral health from the records.
Communication between the dental team members (clinical and non-clinical) can also be aided if the recorded notes are accurate and clear.
Other reasons to keep accurate and clear notes include the patient may complain or have a problem arise in the future from a previous dental treatment. The records being contemporaneous will help both the dental practice and the patient.
The duty to keep clear and accurate records falls under a number of regulations. The Care Quality Commission (CQC) has powers under the Health and Social Care Act 2008 (the 2008 Act) to access dental records for the purposes of exercising their functions (which includes checking that registered providers are meeting the fundamental standards). Other legal requirements covering the keeping of records include the Data Protection Act 1998, the Human Rights Act 1998 and the common law duty of confidentiality.
The Ionising Radiation (Medical Exposure) Regulations 2000 IR(ME)R also require the records to have a certain amount of information about the radiographs, which form part of the patient’s notes.
The main bodies for regulating the records are the General Dental Council (GDC) and the Care Quality Commission (CQC).
Under the GDC New Dental standards, Principal 4: Maintain and protect patients’ information, it states:
- 4.1 You must make and keep contemporaneous, complete and accurate patient records.
- 4.2 You must protect the confidentiality of patients’ information and only use it for the purpose for which it was given.
- 4.3 You must only release a patient’s information without their permission in exceptional circumstances.
- 4.4 You must ensure that patients can have access to their records.
- 4.5 You must keep patients’ information secure at all times, whether your records are held on paper or electronically.
The other main regulating body is the CQC. The CQC will use your clinical notes to see how you manage the risk in your practice. During their inspections, they may see parts of records in order to address and collaborate evidence to see how well the risks in the dental practice are managed. They will not only look at the records but they will also ask staff and patients about the treatment and the quality of care that they have received.
The main aspect of a CQC inspection normally comes under the Key Lines of Enquiry (KLOE) which will inform the judgement against the safe and effective key questions:
- S3: What systems are in place to keep people safe and safeguard them from abuse?
- E1: Are people’s needs assessed and care and treatment delivered in line with current legislation, standards and evidence based guidance?
- E4: Is people’s consent to care and treatment always sought in line with legislation and guidance?
The CQC inspect the dental records in line with the guidance provided by the Faculty of General Dental Practice (FGDP) for clinical examination and record keeping. Usually they will only look at a couple of records, however where they are concerned about something they may look at more records. If however, your practice has run their own audits, then the results of the audits may be sufficient and the CQC may not even look at the records themselves.
The mandatory requirements
The records should be accurate, clear, up to date, complete and legible. They should also be appropriately stored, retained and disposed of. Patients’ information should be protected and only shared when appropriate or necessary.
The FDGP guidelines and the GDC standards require there to be:
- An assessment of the patient which must include a current or updated medical history.
- A diagnosis (where appropriate) to inform the treatment plan for a patient.
Under the FDGP Guidelines and GDC standards, NHS contract obligations require treatment options and advice which forms part of the consent process.
Under the IR(ME)R 2000 Regulations, if dental X-rays are taken the following should be recorded:
- QA score.
The CQC also recommend you follow the professional guidelines below for record keeping. These include FDGP guidelines and GDC standards.
A recognised structure to the dental assessment could include:
- identification data
- medical history/disease risk assessment
- dental history
- clinical examination
- radiographic examination (if applicable)
- diagnosis (where appropriate)
- treatment plan
- reference to consent
- progress notes.
To aid diagnosis the dentist may use:
- periodontal screening tools such as the BPE scoring system and or gingival (gum) pocket depth measurements for periodontal (gum) disease
- specific soft tissue examinations for conditions affecting the soft tissues of the mouth
- dental X-rays/radiographs
- screening methods for dental decay.
Details of the dental treatment carried out should include:
- details of any products supplied or administered to a patient including the manufacturer and batch number used
- details of dental procedure, post-operative instructions, etc
- if antibiotics or other drugs are prescribed then justification for the prescription type, dose and duration should be included.
If treatment was carried out using injected local anaesthetic, the following needs to be recorded to comply with EU legislation Regulation (EC) no. 726/2004:
- type of drug
- route of administration
- volume used
- manufacturer, batch number and expiry date (however this may not necessarily be recorded in the patients notes but recorded elsewhere in the practice as part of practice wide policy on the storage of medicines).
The following are guidelines for record keeping, including FDGP guidelines, GDC standards, and NHS obligations:
- details of the different treatment options with their risks and benefits should be included in records
- written consent forms should be kept for some treatment, e.g. sedation
- for written treatment plans detailing individual treatments and their costs they should make it clear what is being proposed as NHS treatment and what as private treatment
- relevant NHS PR forms or FP17DC forms should be used.
Other guidance for dental practices on record keeping may include details about other preventive advice in relation to keeping the teeth and associated mouth structures healthy, giving due regard to the DOH toolkit Delivering better oral health – an evidence based toolkit for prevention.
Other information you may want to keep in order to help keep full patient records may include:
- study casts
- audio visual recordings of consultations
- laboratory prescriptions
- statements of conformity
- referral correspondences
- investigation reports
- safeguarding issues
- anything you think is relevant to the patient’s oral health.
Remember that all records should also indicate who they were written by, so some form of identification or signature is necessary.
Keeping on top of patient records in practice
An ideal way to ensure the practice keeps on top of the notes is to audit different aspects of the patient records from time to time. There are various audits you can carry out and here are a few examples to get you started.
Check on the medical history as follows:
- this can be done for each clinician separately
- check whether updates on the medical history has been taken at each visit
- check whether the medical history form been signed by the patient at each visit to indicate an update.
Periodontal health checks may include:
- check if the periodontal examinations have been carried out, and followed through
- check that a BPE chart been done every examination.
Oral hygiene checks:
- check that the oral hygiene has been noted
- check that the oral hygiene advice been given, including diet, fluoride use, and the affect of tobacco and alcohol on oral health.
Dental recall checks need to be done as follows:
- check that recalls have been made at correct intervals depending on their caries status as per NICE guidelines etc
- check that audits of dental recalls are reviewed with the practice as a whole, in order to achieve a better system for record keeping.
Dental professionals are required to make and keep accurate dental records of care provided to patients. There are numerous aspects to keeping full and accurate records and any information you feel is important should be noted in the records. Remember each patient is different so the guide above should only be used as a template and anything relevant to the patient should also be recorded in the notes. This will also help with dealing with complaints that may arise as contemporaneous records will help to defend or negotiate a settlement.
- Dental mythbusters 8: Dental care records, GDC: https://tinyurl.com/ycdzqr4b
- Clinical Examination and Record-Keeping, FGBD, May 2016: https://tinyurl.com/ybexhb9h
- Principle 4: Maintain and protect patients’ information, Standards for the dental team, GDC: https://tinyurl.com/ycydrh63
- Clinical guideline [CG19] Dental checks: Intervals between oral health reviews, NICE, October 2004: https://www.nice.org.uk/guidance/cg19
- Delivering better oral health – an evidence based toolkit for prevention, Public Health England, March 2017: https://tinyurl.com/p8sw4d4
About the author:
Dr Shilla Talati BDS graduated from Guys Hospital in 1999 and has been in general/private practice ever since. She was a partner MD of Dental Perfection in Coventry for several years, where she had a special interest in the management side of her dental practice. She has run several courses for the GDP in general practice and is now involved in practice management issues, including staff training, compliance monitoring, and staff motivation.