From Volume 49, Issue 9, October 2022 | Pages 771-774
Dentists are required to make and keep accurate dental records of care provided to their patients. As such, dentists should familiarize themselves with data protection legislation and how that impacts their practice. This article discusses the benefits of good record keeping, the use of templates in record keeping, access to and retention of dental records and the benefit of audit to ensure record keeping is meeting current standards.
Good record keeping is not only a GDC requirement,1 but an expectation for the competent professional practice of all healthcare professionals. In general, the benefits of good record keeping are to:
With an increasing focus on dentistry moving towards a more integrated care pathway approach, adopting a more consistent way of recording patient information is key for better information sharing, care planning and patient safety. The 2019 NHS England and NHS Improvement standards,3 which apply to NHS practices only, were agreed between commissioners, regulators and the profession. However, there has been considerable controversy surrounding them because some elements contradict the FGDP/College of Dentistry guidance.4
The standards3 include three separate tables to show what information is considered essential, aspirational, conditional, or not required for recording in patient records for each of the following scenarios:
The FGDP/College of Dentistry guidance4 also uses the same scenarios of a new patient examination, recall examination and urgent/emergency examination; but uses different terminology. Instead of ‘essential’,³ the FGDP guidance uses the term ‘baseline’4 to describe data that should be recorded unless there is a strong clinical reason not to. The definitions are as follows:
Table 1 is a combined table that shows which pieces of information to record for each scenario as per the standards³ and the FGDP guidance.4 The key pieces of information that are required for all record keeping, regardless of appointment type, are the patient's name, medical history and whether radiographs have been taken. All radiographs need to be recorded and justified, clinically evaluated and quality graded. The FGDP guidance4 and IRMER regulations5 give very clear, nationally accepted, guidance on the appropriate use of radiographs in dentistry.
| New patient examination | Recall examination | Urgent/emergency examination | ||||
|---|---|---|---|---|---|---|
| FGDP | NHS England | FGDP | NHS England | FGDP | NHS England | |
| Personal information | ||||||
| Name | Baseline | Essential | Check | Essential | Baseline | Essential |
| Date of birth | Baseline | Essential | Check | Conditional | Baseline | Conditional |
| Telephone | Baseline | Essential | Check | Aspirational | Baseline | Aspirational |
| Address | Baseline | Essential | Check | Aspirational | Baseline | Aspirational |
| Occupation | Baseline | Conditional | Check | Not required | Conditional | Not required |
| Payment method | Baseline | Essential | Baseline | Aspirational | Baseline | Aspirational |
| Medical history | Baseline | Essential | Baseline | Essential | Baseline | Essential |
| Reason for attendance | Baseline | Essential | Baseline | Conditional | Baseline | Essential |
| Social history | ||||||
| Smoking | Baseline | Aspirational | Check | Aspirational | Conditional | Conditional |
| Alcohol | Baseline | Aspirational | Check | Aspirational | Conditional | Conditional |
| Diet | Aspirational | Aspirational | Conditional | Aspirational | Aspirational | Not required |
| Contact sports | Conditional | Conditional | Check | Not required | Conditional | Not required |
| Musical instruments | Conditional | Not required | Check | Not required | Conditional | Not required |
| Chewing unrestricted | Baseline | Conditional | Check | Conditional | Conditional | Conditional |
| Dental anxiety | Baseline | Aspirational | Conditional | Conditional | Conditional | Conditional |
| Effect of dentition on quality of life | Conditional | Conditional | Not mentioned | Conditional | Not mentioned | Not required |
| Examination | ||||||
| Extra-oral examination | Baseline | Essential | Baseline | Aspirational | Baseline | Conditional |
| Soft tissue examination | Baseline | Essential | Baseline | Essential | Aspirational/conditional* | Conditional |
| BPE | Baseline | Essential | Baseline | Essential | Conditional | Conditional |
| Initial charting and update of teeth | Baseline | Essential | Baseline | Aspirational | Conditional | Not required |
| Caries | Conditional | Essential | Baseline | Essential | Conditional | Conditional |
| Defective restorations | Conditional | Essential | Baseline | Essential | Conditional | Conditional |
| Existing restorations | Conditional | Essential | Check | Aspirational | Not mentioned | Not required |
| Previous endodontic treatment | Conditional | Aspirational | Conditional | Conditional | Not mentioned | Not required |
| Mobility of teeth | Conditional | Aspirational | Conditional | Aspirational | Conditional | Conditional |
| Prosthesis | Conditional | Essential | Conditional | Conditional | Not mentioned | Conditional |
| Occlusion | Baseline | Aspirational | Conditional | Conditional | Conditional | Not required |
| Occlusal abnormality | Conditional | Aspirational | Conditional | Conditional | Conditional | Conditional |
| Toothwear | Conditional | Aspirational | Conditional | Conditional | Not mentioned | Conditional |
| Recall Interval | Not mentioned | Aspirational | Not mentioned | Aspirational | Not mentioned | Not required |
| Radiographs | ||||||
| Record and justify radiographs | IRR/IRMER** | Essential | IRR/IRMER** | Essential | IRR/IRMER** | Essential |
| Clinical evaluation of radiographs | IRR/IRMER** | Essential | IRR/IRMER** | Essential | IRR/IRMER** | Essential |
| Quality of X-rays graded | IRR/IRMER** | Essential | IRR/IRMER** | Essential | IRR/IRMER** | Essential |
Controversially, smoking cessation advice, checks on alcohol intake and diet advice are only considered aspirational, as are carrying out an extra-oral examination on a recall patient and assessing occlusion for new patient assessments. Many clinicians feel as though these should fall into the essential category. Much of the reason for these anomalies is because the standard was created using the Delphi technique.
The standards3 also stress the importance of using clear and consistent terminology within a recognized and structured patient-centric format. The requirement for ‘clear and consistent terminology’ implies that the specific terminology used in the document needs to become the language used in patient care records.
It is also important to document actions, both done or not done, with a rationale, particularly when the action deviates from an agreed protocol. For example, if radiographs were indicated, but not taken due to a patient's wishes, or if a BPE was indicated, but not possible owing to lack of patient cooperation.
Dental care professionals are also required to carry out and evidence the following risk assessments:
The National Institute for Health and Clinical Excellence (NICE) has recommended that these individual risks of oral disease are used to determine the recall interval between dental examinations. The longest interval for patients under 18 years of age should be 12 months, while for patients over 18 years, it should be 24 months.6
One way for dentists to ensure that all relevant information is recorded is to use automatic templates with text prompts. Given the busy lives of dental professionals and the need for records to be written contemporaneously,1 time-saving measures such as these can be very welcome.7 However, records need to be reviewed carefully so that the details accurately reflect that particular patient contact. An inaccurate account of what happened at the appointment can make it difficult for a dentist to justify what information was actually provided to a specific patient if a complaint arises. Examples of entries that could be inappropriately used in pre-populated templates include:
D'Cruz and Rattan8 reported an interesting case where the patient's time in the surgery was recorded as only a few minutes, but the notes suggested extensive discussions occurred during the short appointment time. It is thought that in the future, additional data (such as appointment length) may be requested, as well as clinical records, during medico-legal cases.
The Dental Defence Union (DDU) suggests that it might be more appropriate to have a checklist for the information to be provided before, during and after certain treatments, rather than an automatic entry for the records.7
The Data Protection Act (2018)9 is the UK implementation of the General Data Protection Regulation (GDPR). This Act states that all personal records should be kept safely and securely.
Patients, or the patient's representative if the patient has died, have a right to see their healthcare records under the Data Protection Act9 or the Access to Health Records Act 1990,10 respectively.
Access to a patient's records by other people/organizations must only be given if necessary, and with necessary and appropriate safeguards. Dental Protection recommend that if access to a patient's records is requested by somebody other than the patient (eg police, school, employer etc) then dentists should contact their indemnity providers for advice.11 If there is a court order or a statutory right to compel disclosure, then disclosing information would not breach the dentist's professional duty to maintain confidentiality. If a dentist decides it is necessary to disclose, they should consider whether to ask for the patient's consent, whether the disclosure can be anonymized and limit the disclosure to the extent necessary.
The Data Protection Act also states that personal records should not be ‘kept longer than is necessary.’9 There is, however, no definition of ‘necessary’; this will depend on individual circumstances. Appendix II of the Record Management Code of Practice12 states that dental records (including clinical notes, study models, radiographs etc) should be kept for a minimum of 15 years, and 2 years for finance-related records. Children's records must be maintained for either 15 years or until the patient is aged 25, whichever is longer.4 After this time, the record should be destroyed in a manner that will maintain confidentiality. Dental Protection suggests that, if a patient asks to see their record after the 15-year period, it is ‘reasonable to say that it was destroyed because it was no longer necessary to be kept’ and that there is no ‘suggestion that the patient should be told before destruction.’11
Record keeping is a good subject to audit in order to ensure that gold standards are being met. There are a number of good-quality, record-keeping audit templates freely available online. The Care Quality Commission (CQC) states that as part of their inspections, ‘they may review the practice's protocols for completing dental records in line with FGDP guidance on clinical examinations and record keeping.’13 The purpose of looking at dental care records is not to assess the individual clinician or audit the content, but to assess compliance with standards. The CQC also state that if record audits have been systematically undertaken, they ‘may look at these audits and their subsequent action plans to provide evidence for their key lines of enquiry.’13
In summary, record keeping is a key part of day-to-day life for dental care professionals, and the quality of record keeping reflects the standard of professional practice. Guidance around this topic does change, so it is important to keep up to date with the latest legislation and standards.
