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Record Keeping Policy

Record Keeping Policy

We record patient information in a number of locations

  • Computer
  • Appointment book
  • Record cards
  • Letters
  • Receipts
  • Complaints

Patient records should always be kept secure and this policy should be read in connection with a number of other policies relating to patient record, confidentiality, security and visit protocols (examination, hygienist etc)

  • The actual record card would normally contain

Medical histories (see separate policies in the CQC Folder)

Radiographs (see separate policies in the CQC Folder)

Correspondence received and also photocopies of correspondence sent)


Clinical records

  • Record cards are normally written up

By the hygienist for treatment she has carried out

By the receptionist for information gathered at the reception

By either the dentist or the nurse (then checked by dentist) for treatment done by the dentist

  • Clinical records should be read in combination with the computer record and would normally contain

A baseline charting

An up to date charting at each subsequent examination visit.

A record of soft and hard tissue examination

Any patient observations

All error should be scored out with a single line, signed and dated with corrections written alongside. 

All our staff MUST read all the documents below during the training and induction process.  These are all located in the CQC Folders.

  1. Procedure for Child Check up.
  2. Procedure for Adult Check up
  3. Medical History Policy
  4. Ways to improve Dental Health of our younger patients
  5. Working with Dental Laboratories Practice Policy
  6. Data Security Policy
  7. Data Protection Code of Practice
  8. Patient Confidentiality and Caldecott report
  10. Location of Patient Record Cards
  11. Practice Policy for New Staff Training
  12. Key Points on Consent: The Law in England When do health professionals need consent from patients?
  13. Referrals Policy
  14. Policy for making clinical decisions
  15. Missed Appointments Policy
  16. Promoting Dental Health Policy
  17. Procedures for an Emergency Appointment
  18. Procedures for Referral to Leagrave
  19. Procedures for a new patient
  20. Statement of responsibilities
  21. Policy for working with and prescribing to Dental Hygienists and therapists
  22. Dental Nurse Duties
  23. Dental Treatment (Nurses Roll)
  24. Opportunistic mouth cancer screening checklist
  25. Notation for dental treatment
  26. Current Practice Procedures
  27. Various Clinical Audits
  28. Procedure for all our HTMO1-05

Policy Implemented 20/10/05 and Reviewed Yearly                                                  Next Review of Policy Due:20/10/12