Record Keeping

• Patient Consent Form
• Referral Letter
• Record Keeping

Uniformity in patient's treatment records is an important prerequisite for providing optimal oral health. IDA has therefore drafted guidelines for maintaining records which would result in good dental practice.
The dental records should reflect accurately the interaction between patients, clinicians and any related services.

Suggestions

Entries should be made without delay of all the events worth recording.

• All records should be original, complete, clear, accurate, updated and easy to understand.
• When referring a patient to a specialist, provide a written referral form to the specialist and file a copy in the patient's record together with the specialist's report.
• Individual records should be stored securely, not left unattended or in public areas.
• No entry should be erased.
• All entries made in pen should be legible and reproducible.
• All errors in the records should be indicated and the correct entry should be mentioned along with the date, time and a signature.
• Additions should be separately entered with date (and time).
• It is important with computerised records that the clinician ensures that the information is correct before confirming the entry.
• Corrections or errors in the computerised records should also be mentioned.
• Findings of extra- and intra-oral clinical examinations should be recorded. The method of recording may be standardised using diagrammatic charts to allow rapid and simple comparison in the future.
• An evaluation of the periodontal status by charting- including location and measurement of pockets, gingival bleeding, mobile teeth, furcation involvement, trauma and any disease process present, should be undertaken.
• Any existing radiographs should be viewed for usefulness in diagnosis and the need for further radiographs and any other special tests should be recorded together with their results. Last, there should be a short summary of observations and comments pointing towards a differential and definitive diagnosis.

Need for Record keeping

• Diagnosis or the ongoing treatment procedure and long term follow up care of the patient.
• Conducting clinical trials.
• Administrative or any other purposes.
• Promote teaching and research.
• Evidence against litigation.
• Case review purpose.
• Promote good clinical and laboratory practice.
• Historical purposes.
• Serve as the basis of accreditation.

Computer Records

The standard and the manner in which the computer records are maintained depends on the data management and storage method adopted. This can range from simple tabular form to full chart based presentation. Practice management suppliers should be encouraged to improve and update their systems regularly.
Computer-based patient records should fulfill the following critera:

• The data should be entered in a way so that the old information be overwritten and the new information can be added.
• The data should be encrypted and protected by a password so as to prevent any unauthorised person from gaining access.
• There should be a copy of the data available in the dental practitioner’s room in a read only format.
• Back up copy of the data should be stored in a different computer-drive so as to protect it from tampering or to compare with the original data in case of suspicion of tampering.
• Back up system to retrieve the data should be tested from time to time.
• Irrespective of any future change in the technology, the old data entered should be capable of retrieval.
• The right of the patients to privacy, security and confidentiality should be protected at all times.

Manual Records

The following basic information should be maintained in all patient records. This includes:

• Patient Information

  Accurate general patient information which includes the patient’s full name, address and contact details. It should also include the time and date of the patient’s visit.

• History

  A detailed record of the patient’s medical history should be made. The practitioners should be satisfied that the information is correct. This information is sensitive and should not be made available to those who are not involved in the clinical care of the patient.

  A detailed medical history form can be made available for the patients.ss

• Dental History

  Before the formal first clinical examination, the dental history should record details of previous analgesia/anaesthetics, any oral allergic reactions not recorded in the medical history, previous dental experience, including the most recent and any other information the patient volunteers to give. Patients should be questioned with respect to:

• • Their ability and confidence to chew food.
  • Sensitivity to hot or cold stimuli.
  • Previous endodontic treatment.
  • Previous periodontal treatment.
  • Previous oral surgical procedures.
  • Previous orthodontic treatment.
  • Previous restorative procedures involving fixed and removable prostheses.
  • Habits/ Behavioral History
    • This includes:
      • Potential risk behaviour such as frequency and amount of sweet intakes, smoking, gutka, pan, chewing tobacco, erosive foods/drinks and alcohol intake.
      • Oral habits like grinding, clenching or other habits that may interfere with the treatment.
      • Oral hygiene awareness.
      • Tooth-brushing-frequency and method.
      • Use of mouthwash.
      • Fluoride supplements.
      • Other oral health aids.
      • Any physical impairment such as loss of hearing or eyesight.
• Chief Complaint

  A detailed record should be made for the reasons why the patient’s needed the dentist. The record should be made in patients own words as far as possible. Accurate description of the pain, known lesions or any conditions present on initial examination or mentioned by the patients should also be noted.

• Clinical Examination

  A record of a thorough clinical extra and intra oral examination. The method of recording may be standardised using diagrammatic charts or examination forms to allow rapid and simple comparison in the future.

  Any existing radiographs should be viewed for usefulness in diagnosis and the need for further radiographs and any other special tests should be recorded together with their results. Last, there should be a short summary of observations and comments pointing towards a differential and definitive diagnosis.

• Radiographs

  It is important that all the radiographs are maintained in order. Both pre and post treatment radiographs should be preserved along with the radiograph report.

• Diagnosis and Treatment plan

  A written treatment plan should be constructed and maintained by the dental practitioner and a copy of the plan should be given to the patient. Records, radiographs, models, photographs and clinical details should be retained by the practitioners for a minimum period of eight years.

  The treatment plan should include the proposed method for dealing with the patient's dental problems and describe the anticipated outcome of treatment. It should also include the materials, drugs and a brief description of the treatment procedure. Alternative treatment plans should be discussed and noted together with reasons for selection or rejection.

  It should also be noted that definitive treatment may be influenced by the success of the initial phases of treatment and further patient co- operation in the post treatment phase.

• Referring to a Specialist

  Any need for referral for specialist assistance should be recorded.

• Treatment plan signed

  Patients should be given the most appropriate treatment options along with the options for alternative treatment procedures. Patients consent to treatment should be obtained and noted. The treatment plan should be signed by the patient indicating their acceptance. Patient's refusal for accepting the recommended treatment should also be recorded.

• Patient Fee

  The patient should be given complete details of the total expenses involved in the treatment procedure. Where a patient fee is due, this should be recorded.

  It is very important that an accurate financial record is maintained along with the details of date, time and the mode of payment.

• Confidentiality

  Patients have a right to expect that their personal information shared in the course of their health care will not be disclosed without their knowledge. The duty of confidentiality is towards all patients, including mature and immature minors and adults who lack the capacity to take decisions for themselves. Non- disclosure is held valid even after the individual's death. There are many instances when confidentiality can be breached unintentionally, such as leaving a message with a third party about the patients appointment with the dentist or discussing personal information in the waiting room in front of other patients.

• Treatment Progress Records

  The treatment record is a dynamic document that will record the progress of an individual and any subsequent course or courses of treatment.It must include:-

• Date and description of treatment.
• Type and reason for that specific treatment based on the diagnosis.
• Any discussion regarding choice of treatment and materials used together with any tests, such as thermal, percussive, electrical or other vitality tests.
• Name of clinician who provided the treatment.
• Any medications dispensed or prescribed with details of the dosages.
• Any significant advice concerning the post- operative complications or instructions given to the patient, either verbally, in writing or over the telephone.
• Any changes to the agreed treatment plan.
• Any advice given to the patient relating to diet, smoking or oral hygiene.
• A written report of the results of any radiographs exposed including the reasons for those of no diagnostic value and the number of repeats of the latter.

A differential diagnosis should be recorded. Full details of the anaesthetic and analgesic used should be recorded including the drug name, dose and site of administration, any adverse reaction should be noted. When the entire treatment plan is completed, there should be a final summary and conclusion indicating the prognosis along with the patient instructions for continued care and recall.

• Retention of Records

  It is difficult to maintain a standard record keeping format which can be accepted internationally. Dental records contain both clinical and personal details. Such records simplify both the future treatment and satisfy the legal requirement of record- keeping. Ideally records should be retained on a permanent basis. The Indian Dental Association recommends that the records, radiographs, models, photographs and clinical correspondence should be securely retained for at least the legal minimum period of eight years.

• Examination by Patient needs

  Patient examination requires categorizing the patients in various subgroups. The subgroups of patients are new patients, recall patients, unscheduled patients and patients requiring referral.

• New patient

  Let the patient describe any symptoms or other abnormalities experienced, then carry out intra-oral and extra-oral examinations for signs of abnormalities and give appropriate treatment.

• Recall patient

  A recall patient must be given additional encouragement to maintain their oral health and motivation to revisit the dentist. Patients must be seen at proper intervals on the basis of their risk-level. During recall the patient must be motivated to manage or modify an oral habit which leads to poor oral health.

• Unscheduled examination

  Patients in pain or in emergency should be promptly diagnosed and treated. The complete treatment procedure must be explained to the patient in order to prevent the reoccurrence of the problem.

• Patients needing referral

  Accurate information must be sent to the concerned practitioner. A referral letter should contain the diagnosis details and the treatment procedure selected by the referring practitioner.