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Dental mythbuster 8: Dental care records
Dental professionals are required to make and keep accurate dental records of care provided to patients.
Accurate dental records can help practitioners to reach a diagnosis by providing detailed information about a patient’s changing oral health. Detailed records can also help to prevent adverse incidents, for example, if the records are not clear the wrong tooth could be treated. Records should also enable another clinician to easily understand a patient’s current state of health and the nature of any care that has been given.
One of the fundamental criteria used to manage risk in a dental practice is keeping good quality clinical records. During inspection we may ask to see parts of a dental care record to corroborate evidence of what staff and patients tell us about the quality of care. In particular, the evidence we gather from the dental care record can help answer these Key Lines of Enquiry (KLOE) which will inform the judgement against the safe and effective key questions:
- What systems are in place to keep people safe and safeguard them from abuse? (S3)
- Are people’s needs assessed and care and treatment delivered in line with current legislation, standards and evidence based guidance? (E1)
- Is people’s consent to care and treatment always sought in line with legislation and guidance? (E4)
As part of the inspection, we may review the practice's protocols for completing dental records in line with guidance provided by the Faculty of General Dental Practice regarding clinical examinations and record keeping. The purpose of looking at dental care records is not to assess the individual clinician or audit the content. We recognise that there are particular sensitivities about patient records held by dental practices and will only use our powers to look at a patient's dental records where it is necessary. We will always refer to and apply the 'necessity test' set out in CQC's Code of Practice on Confidential Personal Information. Therefore looking at one or two records to corroborate what dental team members and patients tell us should be sufficient, but we may need to look at more, particularly when we have concerns.
If records audits have been systematically undertaken, the audit findings and any subsequent action plans may provide sufficient evidence to answer the KLOEs and we may not need to look at individual dental care records.
CQC has powers under the Health and Social Care Act 2008 (the 2008 Act) to access dental records for the purposes of exercising our functions (which includes checking that registered providers are meeting the fundamental standards). These powers are always balanced against our responsibilities under the Data Protection Act 2018, the Human Rights Act 1998 and the common law duty of confidentiality. It is also vital that we respect and protect the privacy and dignity of patients, and maintain their trust in CQC and in the confidentiality of their records.
Confidential records must only be accessed where it is necessary for inspection, and access must be proportionate (do not access more records than necessary and avoid particularly sensitive records unless there is an exceptional reason to access them). Remember, you may be committing a criminal offence if you disclose confidential personal information inappropriately.
What we would expect to see from the dental care records to answer KLOE (S3, E1, E4)?
In addition to the items listed below, we are looking to ensure that patient records are accurate, complete, legible, up to date, stored and shared appropriately.
- 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
- Treatment options/advice which forms part of the consent process
Professional guidelines: IRMER 2000 Regulations
- If dental X-rays are taken the following should be recorded:
- QA Score
The patient’s complaint / purpose of appointment and could include a documented pain history or history of any presenting complaint.
Best practice standards should not be misrepresented as minimal standards, but may help when deciding if notable practice has been identified.
- A recognised structure to the 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 treatment carried out:
- Details of any products supplied or administered to a patient including the manufacturer and batch number used
- Details of procedure, post-operative instructions etc.
- If antibiotics or other drugs are prescribed then justification for the prescription type, dose and duration
- If treatment was carried out using injected local anesthetic, record:
- Type of drug
- Route of administration
- Volume used
- Manufacturer, batch number and expiry date (however this may not be recorded in the patients notes but recorded elsewhere in the practice as part of practice wide policy on the storage of medicines.
- Details of the different treatment options with their risks and benefits
- Written consent forms for some treatment e.g. sedation
- Written treatment plans detailing individual treatments and their costs; making it clear what is being proposed as NHS treatment and what as private treatment
- Relevant NHS PR Forms or FP17DC Forms
- Other advice 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’
- Last updated:
- 27 July 2021