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clinical record keeping policy

This policy sets out the principles that hygeia dental care applies in the compilation and management of clinical records.

general principles

Patients’ clinical records must:

  • Be contemporaneous and dated (NB records made using the clinical software “Exact” are automatically dated by the system).
  • Record, as soon as practicable, relevant verbal communications with patients about their care and treatment.
  • Be clear, factual, accurate and comprehensive.
  • Be signed by the dentist or other practitioner, such as a hygienist or therapist.  Our records are kept using the Exact software system.  The software itself keeps a record of the person who has added or edited the notes, though we have now started adding details of the individual who made/charted a note (new as from September 2016).
  • Where not made on computer, be neat, legible and written in ink.
  • Be confined to that which is strictly necessary.
  • Not be derogatory.
  • Maintain patients’ dignity.
  • Be such that disclosure (refer to Confidentiality Policy and Data Protection Policy) would not be problematic.

security, confidentiality and data protection

Refer to the separate, detailed practice policies: Data Security Policy, Confidentiality Policy and Data Protection Policy.

dental imaging

At hygeia we believe that use of dental imaging, ie digital x-rays and digital intra-oral camera pictures, is an essential part of good record keeping and vital in communicating treatment needs and outcomes to patients.  We will routinely:

  • Take intra-oral camera images of areas of concern within the patient’s mouth.
  • Take periapical and bitewing x-rays in accordance with the FGDP’s criteria for selection in dental radiography (refer to our local rules).
  • SHOW THESE TO THE PATIENT so that they may more readily understand proposed treatments and give informed consent while also seeing for themselves the treatment outcomes.  Both x-ray and intra-oral camera systems are digital allowing the instantaneous capture of images which can be shown to the patient immediately.  A screen is positioned in the dentist’s surgery to allow the patient to easily view the images while discussing them with the dentist.
  • Review previously captured images and x-rays prior to the start of each patient appointment.

Images are stored using the Vixwin dental imaging software and are directly linked to the patient’s records within the Exact patient database to facilitate fast retrieval of stored pictures for review.  The system keeps a record not only of which patient the images relate to, but also the date and time that the images were captured/taken.

standard abbreviations used in clinical record keeping

+, ++, +++ – Indicates an incremental scale, eg Pain+ means bad pain; Pain++ means very bad pain; Pain+++ means severe pain (can also be used in other contexts, such as to describe swelling, decay, bleeding, pus)

# – Broken or fractured

10 or 1* – Primary

20 or 2* – Secondary

Adj – Adjacent

Adv – Advised / advice

AMSA – Anterior middle superior alveolar nerve block

ANK – Appointment not kept

ANUG – Acute necrotising ulcerative gingivitis

Apexit – Zinc oxide eugenol cement

Apt or Appt – Appointment

B – Buccal

BC – Buccal cusp

BOP – Bleeding on probing

BPE – Basic Periodontal Examination

BW – Bitewing x-ray

C/O – Complain of (pain, broken tooth, etc) – basically, a patient requesting an urgent appointment

Ca(OH)2 – Calcium hydroxide

Calc – Calculus

CARS – Caries associated with restorations and sealants

Cart(s) – Cartridge(s)

CBCT – Cone beam computed tomography

C-CLAD – Computer-controlled local anaesthetic delivery system

Comp(s) – Composite filling(s)

CPITN – Community Periodontal Index of Treatment Need

CV – Cardiovascular

DBC – Disto-buccal cusp

Diff – Different

DL – Diagnostic length

DNA – Did not attend

EAL – Electronic apex locator

EDTA – Ethylenediaminetetraacetic Acid

Endo – Endodontic treatment (RCT)

ETB – Electric toothbrush

EX – Extraction

EX15 – Routine examination

EXNP – Examination for a new patient

Expl – Explained

F/F – Full upper and full lower dentures

F/- – Full upper denture

-/F – Full lower denture

Fill(s) – Filling(s)

Freq – Frequent / Frequency

FS – Fissure sealant(s)

FTA – Failed to attend

FTP – Fluoride toothpaste

Fuji – Glassionomer

GI – Glassionomer

GP – Gutta percha

HSMW – Hot salt mouth wash

HSWR – Hot salt water rinse

I – Incisal

IANB – Inferior alveolar nerve block

ICDAS – International Caries Detection and Assessment System

Imps. – Dental impressions

Intensive Therapy – Treatment with the hygienist including plaque charting, OHI, diet advice, thorough supragingival debridement but not extending to/including RSD.  It involves longer appointments of an hour each and is commonly recommended for patients with poor OH, poor diet and/or tooth wear but who do not have deep pocketing (5mm or more).  It can often form part of an SPT (maintenance) programme.

IO – Intra oral

L – Lingual

LA – Local anaesthetic

LHS – Left-hand side

LL – Lower left

LR – Lower right

M – Mesial

MBC – Mesio-buccal cusp

MDD – Medical Devices Directive

MH – Medical history

ml – Millilitre(s)

MTA – Mineral Trioxide Aggregate

MTB – Manual toothbrush

NAD – No abnormalities detected

NHS – National Health Service

NP – New patient

NRMH – No relevant medical history

NTR – Nothing to report

O – Occlusal

OD – Overdenture

OH – Oral hygeine

OHI – Oral hygiene instruction

OPG – Orthopantomogram (panoramic x-ray)

OPT – Orthopantomogram (panoramic x-ray)

P – Palatal

P/- – Partial upper denture

-/P – Partial lower denture

P-ASA – Palatal approach anterior superior alveolar nerve block

PA – Periapical (usually in reference to an x-ray “film” or radiolucent area on an x-ray image)

PC – Palatal cusp

PDL – Periodontal ligament

PE – Partially erupted

PFM – Porcelain fused to metal

POP – Pus on probing

Post-op – Post-operative

PP – Private patient

PPT – Prophylactic periodontal therapy

Pre-op – Pre-operative

Prep – Preparation (eg for crown, bridge, inlay, etc)

Probs – Probably / problems (as the context allows)

PRR – Preventive resin restoration

Pt – Patient

Q – Quadrant

RCT – Root canal treatment/therapy

Rec – Recommended

RHS – Right-hand side

RIA – Recall interval assessment

RR – Resin retained (in reference to a dental bridge)

RRB – Resin retained bridge

RSD – Root surface debridement

Rx – Treatment

S&P – Scale and Polish

Script – Prescription

SDC – Symptoms, diagnosis, consent

Sec – Secondary

Sens – sensitive / sensitivity

SGC – Sub-gingival calculus

SPT – Supportive periodontal therapy

SRP – Scaling and root planing

ST – Soft tissues

STB – Single tufted brush

Sub – Sub-gingival; below

Surg. – Surgical procedure (usually extraction)

SXLA – Surgical extraction under local anaesthetic

TB – Toothbrush

TBI – Tooth brushing instruction

TCA – To come again

TEC – Tetric Evoceram Composite (Ivoclar Vivadent product)

Temp – Temporary

TMJ – Temperomandibular joint

Topical – Topical anaesthetic gel

TP – Toothpaste

TTP – Tender to percussion

UL – Upper left

UR – Upper right

USP – Ultra Safety Plus disposable syringe system

W – Watch

Wand – “The Wand” computer-controlled local anaesthetic delivery system

WG – Wave One Gold system – may refer to nickel-titanium reciprocating endodontic file(s) OR the matched GP

WL – Working length

XLA – Extraction under local anaesthetic

recording diagnosis and planned treatment

Whenever the dentist diagnoses damage, decay, gum disease or another problem that indicates a need for treatment to be performed, this is recorded immediately using the Exact computer software.  The need for treatment is recorded by adding an item of “planned treatment” to the patient chart.  The computer system makes and retains a record of the date that the planned treatment was “charted” and by whom (even after the treatment has been completed and marked as such).  We also make a separate record of the fact of diagnosis and the date that it was arrived at (see codes EXNP – new patient examination – and EX15 – regular examination, for example).

Reasons for the diagnosis can be recorded by the dentist editing items of “planned treatment” to indicate why the need for treatment was identified, though we frequently use dedicated, separate codes to record symptoms, diagnosis and consent (eg see “Fillings” or “Crowns” codes).

A link to the image database also allows easy access to contemporaneous intra-oral camera images and x-ray results, further reinforcing the reasons for diagnosis.  The dentist must explain their findings to the patient and agree which treatment is to be carried out in consultation with the patient.  X-ray findings (reports) are written up as a matter of course for every image taken.  Notes relating to what is shown on intra-oral photographs are only made where this is absolutely necessary, though the fact that photographs have been taken and shown to the patient is recorded in the notes.

Patients are provided with a written treatment plan confirming the treatment that is proposed (or where they have decided not to proceed with all proposed treatment, confirming treatment that has been agreed).  This may be handed to them at the appointment when the treatment was discussed or sent to them afterwards.  The treatment plan is accompanied by information leaflets relating to the proposed treatments (where these are available).

recording consent, refusal and patient’s wishes

Records should provide a synopsis of discussions with a patient that lead to them giving consent – eg records of symptoms, results of tests, a formal diagnosis and the treatment options considered (including any relevant risks and benefits), etc. It is not necessary to obtain a patient signature to evidence that they consented to dental treatment.  Written evidence of consent is only a legal requirement in particular circumstances, such as where treatment is to be carried out under GA or sedation – we do not provide these services.

Where a patient declines to follow a recommended course of action, particularly where this may have an adverse impact on outcomes (eg refusal of RCT/extraction when there is a severe infection), this must be recorded in the patient notes.

We always aim to respect patient choices and preferences, but where a patient’s preferred treatment cannot be provided, the reasons should be explained and this should be recorded in the patient notes.

recording medical alerts, infectious diseases, safeguarding concerns and capacity issues

Where a patient’s medical history indicates there is something important that should be drawn to the attention of the clinician, this is recorded as a “Medical Alert”. Examples may include allergy to penicillin, regular medications, asthma, renal impairment, etc. A Medical Alert causes the cross at the centre of the top of the screen to flash red, drawing attention to it. Hovering the mouse pointer over this icon causes a pop-up to appear with details of the Medical Alert.

Where the patient may be considered a vulnerable adult, and also in cases where they meet the definition (because, for example, they have a carer) but are not considered to be at risk of harm or exploitation, this is flagged as a Medical Alert but prefaced with the word “SAFEGUARDING” in capital letters. The note should give a brief factual explanation: refer to Policy on Child Protection and Safeguarding of Vulnerable Adults.

Where a patient may lack capacity for the purposes of the Mental Capacity Act, or in cases where they may be expected to have impaired capacity but in fact do not, this is flagged as a Medical Alert but prefaced with the word “CAPACITY” in capital letters. The note should give a brief factual explanation as to why the patient is (or is not) thought to lack mental capacity for the purposes of consent to treatment.

Where a patient’s medical history indicates that they have an infectious disease, this is recorded as an “Infectious Alert”. Examples may include HIV and hepatitis. An Infectious Alert causes the cross at the centre of the top of the screen to flash yellow, drawing attention to it. Hovering the mouse pointer over this icon causes a pop-up to appear with details of the Infectious Alert.

NB: Where a patient has both Medical and Infectious Alerts, the cross at the top of their record screen flashes alternately red and yellow.

daily record keeping checks

To maintain record-keeping standards, we carry out daily checks of our record-keeping using a specially designed pro-forma: see Daily Clinical Records Checking Form, version 11, Hygeia Document Database.  These checks allow us to ensure that all records are complete at the end of each session.

Items checked include, but are not limited to, patient details, medical histories, medical & infection alerts, sending of “welcome to the practice” letters & emails, prescribing, recall interval assessment, intra-oral photographs, radiographs, caries risk & assessment of appropriate x-ray interval, setting of recall dates, dental charting, soft tissue checks, recording of symptoms, diagnosis & consent, local aneasthesia, laboratory made items, telephone calls, referrals, periodontal charting and the provision of treatment plans & treatment information leaflets.

record keeping audits

To maintain record-keeping standards, the practice also carries out regular audits of record-keeping.  The results are considered by Joanne Giddy and Neil Phillips and any necessary changes are agreed and implemented as a result. Audits are usually at annual intervals but may be more frequent if this is felt appropriate.

25 records are audited each time.  The audit checks for 95 different items of record-keeping on each record audited.  For full information, refer to “Patient records audit – data capture pro forma – version 7” in the Hygeia Document Database.

Web version 11: 17.8.2018 (reviewed 11.11.2018)
Previous web version: 1.2.2011 (reviewed 25.1.2012); 17.1.2013; 13.3.2013 (reviewed 19.6.2014; 5.6.2015);  4.8.2016; 1.10.2016; 26.10.2016; 8.11.2016; 1.9.2017; 26.10.2017; 7.1.2018

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