5. Clinical record keeping basics

Jessica Zachar; Sowmya Shetty

5. Clinical record keeping basics

Jessica Zachar and Sowmya Shetty

Learning outcomes

Explain the terms clinical record, health information and personal information, and provide examples.
Describe dental records and salient points for good practice for record keeping.
Provide examples of good record keeping.
Know common dental abbreviations that are acceptable to use.

Definitions and examples

Clinical record: This is a comprehensive record of every interaction with a patient. It is vital for diagnosis, planning treatment, managing cases, administering practice, and facilitating seamless transitions of care among clinicians.

Health Information: This is all information about a patient’s health or illness, injury or disability. Some examples are:

Clinical notes recorded of observed symptoms or a diagnosis
Any information about a health service that is currently being utilised or will do so in future
Reports from consultants or specialist
Results of any tests conducted
Prescriptions
Records from a dental visit (Australian Dental Association [ADA], 2016).

Personal information: This includes any detail or viewpoint that might reveal a person’s identity or make it reasonably possible to discern. It encompasses specifics like someone’s:

name
signature
address
phone number
date of birth.

Sensitive information: will need more privacy protection than other personal information. Some examples are:

“racial, ethnic origin
political or religious opinions
sexual orientation or practices
criminal record
biometrics
health/ genetic information
credit information
photographs
employee record information
internet protocol (IP) addresses
voice print and facial recognition biometrics (because they collect characteristics that make an individual’s voice or face unique)
location information from a mobile device (because it can reveal user activity patterns and habits)” (ADA, 2016).

What are dental records and why are they important?

It is important to maintain thorough and up-to-date records as it is crucial evidence in the event of a dispute or legal proceedings. Dentists are both professionally and legally obligated to maintain accurate, clinically relevant, and contemporaneous dental records for their patients. (ADA, 2016). Additionally, clear and accurate health records is essential for the continuing good care of patients and for providing this detail to the next dental practitioner that the patient visits or to the primary health care team. Dental records also play a part in identification in forensic cases.

Dental records play an essential role in documenting:

patient consent provided
any evaluation, provision of oral health care or specifics of treatment provided
any advice provided or discussion around health care.
adherence to insurer, other third-party funding organisations, and government-subsidised dental program regulations
resolution of complaints, medico-legal matters and professional standards evaluations (ADA, 2016).

Dental records can include but are not limited to:

clinical or administrative staff notes
comprehensive written medical history
consent forms
records of correspondence regarding and involving the patient
records of phone conversations with the patient or other consulted healthcare professionals
radiographs and other diagnostic tests or measurements
electronic records including CAD/CAM captures
diagnostic images and interpretations
special test findings
photographs, digital images and videos
records of financial transactions
appointment books (ADA, 2016).

Various national boards have specific guidelines in relation to records and these can be found under Code of Conduct Section 8.3 Health Records.

Some good practice recommendations from the Australian Dental Association includes:

Keep accurate, up-to-date, factual, objective and legible records reporting relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners.
Ensure that records are held securely and are not subject to unauthorised access including electronic records.
Ensure that records show respect for patients and do not include personal judgement, demeaning or derogatory remarks.
Ensure that records are sufficient to facilitate continuity of care.
Make records at the time of patient interaction, or as soon as possible afterwards.
Recognise the right of patients to access information contained in their health records and facilitate that access.
Promptly facilitate the transfer or management (including disposal) of health information in accordance with legislation on privacy and health records when requested by patients, or when closing or relocating a practice (ADA, 2016).

Consent details

Personal information

Sufficient information for patient identification and communication should be recorded, encompassing details like the patient’s full name, gender, date of birth, address (including email and phone number), along with their current medical history, including any documented adverse drug reactions.

Substitute decision maker

The dental record should contain the name, address and contact details of the parent, guardian or substitute decision maker where appropriate and the relationship to the patient.

Consents and restrictions on disclosure

Written consent form – signed.
Where no written consent – Explanation of treatment as communicated to the patient, along with consents obtained from the patient.
Guidance provided to the patient regarding: treatment alternatives, including the choice of taking no action, the pertinent risks and benefits associated with those alternatives, pre- and post-treatment directives, and anticipated results.

Examples for good record keeping in dentistry

References

Australian Dental Association. (2016). ADA Guidelines for Dental Records. https://ada.org.au/getmedia/919be35a-7357-4628-b567-a0a924ba0156/ADA_Guidelines_Dental-records.pdf

Australian Health Practitioner Regulation Agency and the National Boards. (2022). Shared code of conduct. https://www.ahpra.gov.au/Resources/Code-of-conduct/Shared-Code-of-conduct.aspx

Dental Protection. (2023). A young practitioner’s guide to record keeping. https://www.dentalprotection.org/australia/publications-resources/survival-guide/a-young-dentist-s-guide-to-record-keeping

License

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Communication Essentials in Dentistry Copyright © 2024 by The University of Queensland is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.