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Archived: Richard Thompson Dental Practice

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Inspection report

Date of Inspection: 25 April 2013
Date of Publication: 21 May 2013
Inspection Report published 21 May 2013 PDF | 84.87 KB

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 25 April 2013, observed how people were being cared for and talked with people who use the service. We talked with staff.

Our judgement

People were protected from the risks of unsafe or inappropriate care and treatment because of proper records management.

Reasons for our judgement

Patient records were accurate and fit for purpose. We asked the practice manager to explain the use of the electronic patient record. We saw that appropriate information was recorded. We were told that the patient's medical history was checked at each appointment and updated as necessary. There was a menu of treatment options which could be chosen to add standard text. Additional notes could be added. An alert system was used to flag concerns such as allergies, heart or chest conditions or infection control risks. We were told that a “watch” marker could be added to the system so that areas of concern were monitored. We saw electronic records updated during treatment.

We sampled records relating to practice, procedure and staffing and found them to be fit for purpose.

Records were kept securely and could be located promptly when needed. We saw that paper patient records such as medical histories and payment plans were stored in locked filing cabinets and cupboards.

We were told that the quality of patient records was due to be audited in June 2013. We were shown a copy of the check list to be used which covered areas including contact details, medical and dental history, mouth cancer risk factors and consent. We were told that the quality of X-rays had been audited in February 2013 and there were no significant concerns. We were told that staff also informally gave feed back to their colleagues on the quality of record keeping.

We were told that records were kept for the appropriate period of time and then destroyed by incineration by an appropriate contractor.