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.