Oral Health | Clinical and Risk Asessment | The importance of good record keeping

The importance of good record keeping
Session overview
Description
This session introduces the importance of keeping good patient records. The reasons why full, accurate, contemporaneous records are essential are discussed and ‘good practice’ levels of record keeping that comply with existing guidelines are explored. The impact of the General Dental Council (GDC) on standards in patient record keeping is identified.

Learning objectives
By the end of this session you will be able to:

• describe why it is essential to keep good patient records that are full, accurate and contemporaneous
• list the essential components of ‘good practice’ in record keeping
• evaluate the pitfalls of poor records
• identify the guidelines that govern patient record keeping

Prerequisites
Before commencing this session you should be familiar with:

• the Faculty of General Dental Practice’s guidance on record keeping
• the General Dental Council’s guidance on standards in relation to patient records

Making and keeping good patient records is of paramount importance for a number of reasons.

• They are essential to be able to provide quality care.
• They are needed to undertake retrospective or prospective clinical audit.
• They are essential to defend an allegation of inappropriate or failed treatment either by the patient, another dentist or a third party such as a regulatory body, a solicitor, a Primary Care Trust (PCT) or payment plan, etc.
• They are very helpful if a practitioner’s patient is seen in an emergency by a colleague.