Clinical examination & record-keeping: Part 1: Dental records

Abstract

This article forms part of a BDJ series of Practice papers on the subject of clinical examination and related record keeping. The series is taken from the Faculty of General Dental Practice UK (FGDP[UK]) 2016 Good Practice Guidelines book on this topic, edited by A. M. Hadden. This particular article, the first in the series, describes what constitutes dental records. The principles are applicable to electronic and handwritten records. Records will fall below acceptable standards when it is not clear to another clinician what was found, planned, discussed, and what treatment carried out.