Off the record

Abstract

Clinical dental records fulfil a variety of functions. Whilst there is no standard data set for dental records, it is essential that these are contemporaneous--that is, they are 'recorded at the time' A good written record should contain details of the patient's identification data, medical and dental history, clinical examination, diagnosis, treatment plan, reference to consent, and progress notes. This paper covers these aspects in detail, and provides information on how long records should be stored, and who may access clinical records.

Clinical relevance: The recording of contemporaneous patient/treatment information is central to treatment planning and good patient care.