What should be recorded in clinical notes course for Dental Practitioners



This session examines the essential details that should be recorded in a patient's clinical notes for common dental procedures. Good practice guidelines surrounding the retention of patient records are also discussed together with the importance of confidentiality.
Learning objectives
By the end of this session you will be able to:
- describe in detail what constitutes good clinical records
- discuss how much information should be recorded
- identify what is essential and what is 'good practice'
- explain the legislation surrounding the retention of patient records
- demonstrate an understanding of the importance of confidentiality
Many dentists keep medico legally vulnerable patient records. Record keeping is often given little priority, either because the dentist runs short of time or because of a failure to understand how beneficial good patient records are and the pitfalls of poor records. The advent of computer records does not appear to have markedly improved the standard of patient records although they are usually more legible.

Before commencing this session you should:
- complete the e-Den session: Patient assessment/The patient’s profile/The importance of good record keeping
- have a basic knowledge of what constitutes a good patient record and the importance of confidentiality
- be familiar with the Faculty of General Dental Practice's guidance on Clinical Examination and Record Keeping
- be familiar with the General Dental Council's Standards concerning Patient Confidentiality
After qualifying Pat combined general practice with part time oral surgery teaching posts at Manchester and Guys.
She was a founder member and Deputy Chief Dental Officer of Denplan, combining this with part time general practice. Pat was instrumental in the development and implementation of Denplan’s much admired quality and training programmes.
Pat is currently Clinical Director at Oasis Healthcare and the Course Director of the FGDP Certificate in Appraisal of Dental Practices.
She has had a life long interest in helping dentists keep good clinical records and is the author of the record keeping section of the FGDP Key Skills modules.

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