Dental records should provide an accurate picture of a patient’s general health, as well as oral/dental status and any patient concerns or queries. The proposed treatment plan should be highlighted here and any treatment performed should be noted also, backed up with the necessary documentation.
The outcome of the treatment has to be documented, any deviations from expected outcomes should be recorded on the patient’s record. As soon as the dentist is aware that the treatment may be done slightly differently the patient must be informed, this needs to be presented in document form.
Key tips for record keeping
The amount of detail will depend on the patient’s situation, however there should be a certain baseline for all.
Including:
- General information.
- An updated medical & dental history.
- Oral examination results.
- An accurate description of any ongoing treatment.
- A record of the significant findings of all supporting diagnostic aids, tests or referrals such as radiographs, study models, reports from specialists.
- All clinical diagnoses & treatment options.
- A record of planning options, previously discussed with the patient.
- The proposed and accepted treatment plan.
- Proof of consent for the treatment.
- Assurance that patient consent was obtained for the release of any and all patient information to a third party.
- A descriptive report of all treatment performed, including materials and antibiotics used.
- Referral details (if applicable).
- An accurate financial record.
