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RECORD KEEPING |
Record keeping plays a very important role in the dental office. Good records are accurate and legible. Dental records include written notes, radiographs, study models, photographs and correspondence . Radiographs are developed carefully and kept safely. They are readily identified. Study models are stored carefully and give clear identification.
Certain aspects of record keeping are as follows :-
- Patient name, address and telephone number are recorded at the top of the card.
- Initial consent is obtained from the patient.
- A detailed medical history is taken using a printed form . The information is confirmed by the dentist and regularly updated.
- Dental, periodontal and soft tissue examination findings are recorded by the dentist.
- Appointments fixed or cancelled are noted.
- The treatment options discussed with the patient are noted as well as the decided option. If the patient does not consent to any advice, this is made note of and signature of a staff member is witness is taken to avoid any future complications.
- The treatment carried out during every visit is noted as well as its elements such as any special tests like vitality tests, restorative material used, temporary restorations, impressions taken, whether a local anesthetic was used. Radiographs are dated and the results recorded .
- Medications prescribed are noted. Any allergic reactions are also noted.
- Any referral letters are made note of and a copy is made and filed in the patient’s record cared .
- No comments about the patient or their family is allowed to be written in the notes.
- Complaints are documented and any action taken.
- Estimates and treatment plans given to the patient are recorded.
Dental records are solely the property of the practitioner. Dental radiographs are generally kept under the possession of the dentist unless agreed otherwise previously. The records are kept for three years after the last entry. The records comply with security and disclosure. |
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