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Archived: Contemporary Dental

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Inspection report

Date of Inspection: 16 January 2014
Date of Publication: 20 February 2014
Inspection Report published 20 February 2014 PDF

People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)

Meeting this standard

We checked that people who use this service

  • Their personal records including medical records are accurate, fit for purpose, held securely and remain confidential.
  • Other records required to be kept to protect their safety and well being are maintained and held securely where required.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 16 January 2014, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with staff and reviewed information given to us by the provider.

Our judgement

People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

Reasons for our judgement

Patients’ personal records including medical records were accurate and fit for purpose. The electronic and paper records we looked at had been maintained well and were up to date. Records highlighted risks such as allergies or current medical treatments. Electronic records were regularly backed up to prevent records from being lost or deleted. Records indicated how people liked to be reminded about appointments, for example by text messages or phone calls. The patients we spoke with told us they received reminders about appointments in the way they chose. This showed that the provider took steps to ensure information about people remained current.

We heard how reception staff and dental nurses checked patients’ personal information to ensure it was accurately recorded and saw them updating records as required. Medical history forms were completed by patients on arrival for appointments. In all the records we looked at we saw how medical alerts were highlighted to ensure the dental team were aware of any concerns. For example, where a patient was taking medication to thin their blood or had an allergy to certain antibiotics this was clearly indicated.

We saw that soft tissue assessments were recorded as well as risk assessments for caries, gum disease and oral cancer. These assessment records showed that recall appointments were based on risk assessment and patient need and not just for standard annual or six monthly check-ups. Other records such as X-rays were digitally scanned onto patient’s’ computer based records and their quality was checked. The reasons why X-rays were required was recorded in the patient’s notes in a radiographic justification report. Batch numbers of local anaesthetics and dosage amounts were also recorded. Where Intravenous sedation was carried out the provider kept a systematic log of their checks and monitoring of the patient. This showed records accurately reflected the assessments and needs of patients.

Staff records and other records relevant to the management of the services were accurate and fit for purpose. We saw completed records indicating the routine hygiene and infection control checks carried out daily and weekly by practice staff. Current service certificates were in place for radiograph equipment, compressors, autoclave and ultrasonic cleaners. Firefighting equipment such as fire extinguishers as well as emergency lighting were routinely checked by an external engineer annually. This showed the provider had records in place to support the management of their service

Records were kept securely and could be located promptly when needed. Where paper records were needed we saw that patient paper records were stored in a secure area of the practice to protect confidentiality. The electronic patient records on the providers’ computer system were password protected to ensure information was held securely. Computer screens used by staff faced away from the public to prevent breaches of confidentiality. Records were kept for the appropriate period of time and then destroyed securely through a secure external provider. This ensured that records were up to date, reflected the treatment provided and were kept in accordance with the Data Protection Act.