Record Keeping

Over the last 20 years record keeping has become an increasingly vital part of clinical practice. Not only is it a requirement for optimal patient care but is also a medico-legal necessity to accurately record patient information and patient records. These records must be clear, concise, contemporaneous and complete as well as accurate. Furthermore, any changes to patient records should be signed and dated. 

The GDC reflect this in Standard 4.1.1 of the GDC Standards for the Dental Team:  “You must make and keep contemporaneous, complete and accurate patient records” (accessible online at:https://standards.gdc-uk.org/pages/principle4/principle4.aspx):

“4.1.1 You must make and keep complete and accurate patient records, including an up-to-date medical history, each time that you treat patients. Radiographs, consent forms, photographs, models, audio or visual recordings of consultations, laboratory prescriptions, statements of conformity and referral letters all form part of patients' records where they are available.

4.1.2 You should record as much detail as possible about the discussions you have with your patients, including evidence that valid consent has been obtained. You should also include details of any particular patient’s treatment needs where appropriate.

4.1.3 You must understand and meet your responsibilities in relation to patient information in line with current legislation. You must follow appropriate national advice on retaining, storing and disposing of patient records.

4.1.4 You must ensure that all documentation that records your work, including patient records, is clear, legible, accurate, and can be readily understood by others. You must also record the name or initials of the treating clinician.

4.1.5 If you need to make any amendments to a patient’s records you must make sure that the changes are clearly marked up and dated.

4.1.6 If you refer a patient to another dental professional or other health professional, you must make an accurate record of this referral in the patient’s notes and include a written prescription when necessary.”

The FGDP have provided comprehensive guidance on record keeping which can be found below:

Storing patient records

Patient’s are allowed to request their records. However, it is important to note that the physical records belong to the dental practice as opposed to the patient. The patient can simply request copies of their records. It is possible to charge up to £50 for physical copies of records of up to £10 for electronic copies, however, this is discretionary. Furthermore, once a patient requests their records you have a maximum of 40 days to comply with this request but in reality it is good practice to provide them to the patient as soon as possible. 

Another common question is how long should we store a patient’s notes?

As a minimum for NHS and Private Practices notes should be stored for:

For Adults - 11 years after the last patient records entry, or;

For Children - 11 years after the last patient records entry, or, until they reach the age of 25. In this case you hold them for whichever is the longer period of time. 

For more information on Data Protection, confidentiality and when you can disclose a patient information without their consent click below.

For more information on record keeping in dentistry check out the resources below:

https://standards.gdc-uk.org/pages/principle4/principle4.aspx

An introduction to good record keeping

https://www.fgdp.org.uk/guidance-standards/clinical-examination-and-record-keeping-0

https://www.fgdp.org.uk/news/importance-record-keeping

https://www.theddu.com/guidance-and-advice/guides/keeping-good-records

https://www.dentalprotection.org/uk/articles/record-keeping-in-the-uk

https://www.dentalprotection.org/uk/articles/principle-4-maintain-and-protect-patients-information

https://www.theddu.com/~/media/files/ddu/publications/new%20ddu%20guide/ddu_guide_section_4_dental_records.pdf

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/confidentiality

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/protecting-children-and-young-people/keeping-records