The importance of effective record card keeping in dentistry
Published: 16/04/2025
Effective record card keeping is crucial for quality dental care. In this article, our Clinical Services Lead, Lianne Scott-Munden highlights its importance, best practices, and the benefits of regular audits and peer reviews.
Effective record card keeping is a cornerstone of quality dental care. Recent insights from the Dental Complaints Service highlight that a significant number of complaints arise due to clinical treatment issues. In 2024 alone, complaints about clinical treatments increased from 450 to 923. While these complaints may not always be directly linked to record keeping, adequate and detailed dental records can significantly assist in handling and resolving complaints. These records are not just a legal requirement but a vital tool in ensuring patient safety, continuity of care, and the ability to defend against malpractice claims.
Why it’s important
Dental records serve multiple critical functions. They provide a comprehensive account of a patient's oral health, aid in diagnosis and treatment planning, and help prevent adverse incidents. Accurate and detailed records are essential for demonstrating care and competence, complying with General Dental Council (GDC) requirements, and assisting in clinical management. When a complaint arises, well-maintained records offer crucial evidence of the care provided, substantiating the care given and helping resolve disputes effectively.
What constitutes as dental records?
Personal information: Patient's name, birth date, address, and contact details.
Medical history: Detailed medical background and updates.
Initial discussion notes: Reason for the patient's visit and initial consultation details.
Charting: Dental charting and records of examinations.
Examination notes: Findings from clinical examinations and special tests.
Radiographs: X-rays and their interpretations.
Photographs: Clinical photographs for documentation.
Study models: Models created for treatment planning.
Audiovisual recordings: Any relevant audio or video recordings.
Diagnosis notes: Clear documentation of diagnoses.
Treatment options: Discussion of treatment options, including those offered but declined.
Consent evidence: Records of patient consent for treatments.
Treatment plan: Detailed treatment plans.
Treatment notes: Notes on treatments provided, including sedation and anaesthetic details.
Laboratory prescriptions: Prescriptions for lab work.
Prostheses documentation: Certificates and statements for prostheses.
Correspondence: Incoming and outgoing communications.
Payment history: Records of payments and financial transactions.
Best practices for record keeping
Following best practices for dental record keeping ensures accuracy, compliance, and efficiency. Key practices include maintaining consistency, providing detailed and legible documentation, updating records promptly, securing patient information, and regularly training staff on proper record-keeping practices.
Clinical examination and record keeping
For clinical examinations, records should facilitate diagnosis and care planning. This includes:
Extra-oral assessments: Supporting the prescription of antimicrobial drugs for acute infections.
Intra-oral soft tissue assessments: Including oral cancer screening, especially for infrequent attenders or high-risk patients.
Hard tissue charting: Detailing periodontal probing outcomes and using numerical clinical indices for disease severity.
Radiographic practice: Meeting responsibilities under IRMER, including clinical evaluation and documentation of findings.
The importance of six-monthly record card audits
Regular audits of dental records are crucial for maintaining high standards of care. By carrying out audits every six months, they can help identify gaps or inconsistences in record keeping, ensuring that all necessary information is documented accurately and comprehensively. They provide reassurance that legal, regulatory and professionals standards are being followed. The audit will also check that medical histories, treatment plans and consent is all up to date to minimise risks to patient safety. These audits can highlight areas for improvement in clinical and administrative practices, fostering better record-keeping practices among the dental team.
Action planning after audits
Following audits, it’s essential to develop and implement action plans to address any identified issues. This involves:
Identifying gaps: Pinpointing areas where documentation is lacking or incorrect.
Training: Providing additional training to staff on best practices for record keeping.
Monitoring: Establishing ongoing monitoring to ensure improvements are sustained.
Reviewing: Regularly reviewing and updating action plans to adapt to new challenges and maintain compliance.
Peer reviews
Peer review record card audits offer significant benefits in dental practices. They ensure that patient records are comprehensive, accurate, and contemporaneous, which is crucial for medico-legal protection in an increasingly litigation-conscious society. By identifying and correcting omissions, such as the failure to record negative findings, these audits help prevent legal inferences that procedures were not performed. As part of the Denplan Excel Programme we offer peer to peer reviews of Denplan patient records. The programme has demonstrated that improved record keeping leads to better patient communication, consistency in care, and the ability to review and tailor treatment plans effectively. Overall, peer review audits enhance the quality of patient care and support the principles of Clinical Governance.
Effective record card keeping is not just about meeting regulatory requirements; it is about ensuring the highest standards of patient care and safety.
By prioritising accurate and detailed documentation, conducting regular audits, and implementing robust action plans, dental practices can significantly reduce the risk of complaints and enhance the overall quality of care.