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: