4

Dental records
Dental records are an
essential clinical tool for the
dental professional.
A patients records may
include:
clinical notes
radiographs
consent forms
photographs
study casts
audio or visual recordings
of consultations
laboratory prescriptions
statements of conformity
referral correspondence
investigation reports
NHS forms.

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The purpose of records is to

provide:
an accurate picture of
patient treatment and
care which can be used at
every consultation
a means of professional
communication e.g.
between the various
members of the dental
team, and between
members of the dental
team and other healthcare
professionals.

4.1
Keeping good records

Records are an essential part of patient care and can provide evidence if
your standard of care is called into question.
Key points
1. Good patient records follow the four Cs.
a. Contemporaneous - records should be made at, or very close to, the time of
the examination, treatment, observation or discussion, and they should be
dated and signed legibly.
b. Clear - records should be written carefully, so that they can be understood by
anyone who may need to read and interpret them.
c. Concise - records should be just long enough to convey the essential
information.
d. Complete - all aspects of a patients visit should be recorded. This includes:
- presenting complaints
- histories (medical, dental and social)
- dental charting
- findings on examination, including negative findings (e.g. no teeth tender to
percussion)
- diagnosis
- discussions about treatment options and risks
- agreed treatment plan
- consent to treatment
- treatment given
- mishaps and complications.
2. Request forms, such as those for pathology reports or radiographs, should be
completed clearly with adequate detail, dated and signed legibly.
3. All reports should be seen, evaluated and initialled before being filed, with any
abnormal results noted in the clinical record and any action recorded.

Our advice
Try to avoid the use of abbreviations
as far as possible as they may be
misinterpreted or misunderstood.
Use one system of dental charting
(Palmer notation, FDI notation or
another) consistently throughout the
records.
Check dictated and typed notes, or
notes made by somebody else on your
behalf e.g. notes by a dental nurse on
behalf of a dentist. Any errors on paper
records should be crossed out with a
single line and the correction handwritten alongside the error. The notes
should be dated and signed legibly by
the dental professional who dictated
them.

Checklist
Is your handwriting, including your
signature, legible?
Are all notes, including all
amendments to the notes and
contributions from others, signed
and dated?
Have all contributions from third
parties, including reports, been
evaluated and initialled before being
filed?

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4.2
Computer-held records

The same dento-legal requirements apply to digital records as to

manual records.
The four Cs that notes are contemporaneous, clear, concise and complete
remain essential requirements of a computer-held record. (See section 4.1 Keeping
good records).
For dento-legal purposes, your computer software should be capable of producing a
hard copy of records and radiographs. It also needs to be capable of producing a full
audit trail of record creation and modification.

Key points
1. Extra care needs to be taken when completing, or making modifications to,
electronic records to ensure the author, e.g. the dentist, locum or dental care
professional, is clearly identified.
2. Every time a record is created or an existing record is modified the date must be
recorded on the system.
3. Computer-held records must be robustly protected against unauthorised
or unlawful access. They should also be protected against accidental loss,
including corruption, damage or destruction through regular backups. If sending
confidential information, a secure method should be used.
4. The storage of patient identifiable data on personal mobile devices should be
avoided. The Department of Health has said that the movement of unencrypted
data held in electronic format should not be allowed in the NHS and wherever
possible, person identifiable data should always be stored on a secure server.
5. Familiarise yourself with your workplace information security policy, including
the name of the person in charge of data security and follow practice or trust
procedures, for example, on the use of laptops and portable data storage.
6. Computer-held records may be difficult to delete completely from a hard drive
and appropriate IT advice should be sought about data destruction before
disposing of computer hardware.

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Our advice
Check that the specification of a
computer system or software allows you
to fulfil your data protection obligations
before using or purchasing it.

Checklist
Is your IT system adequately
protected from unauthorised access
e.g. is it protected with the use of
strong passwords and is the data
encrypted?
Is your software dento-legally
compliant e.g. does it allow you to
produce hard copies of records?
Does your system provide a full audit
trail?
Do you regularly back up your
electronic records and check that
your back-up is working correctly
and you are able to retrieve/restore
records if necessary?
Do you hold a back-up of your
electronic files in secure off-site
premises?

4.3
Data protection legislation

The Data Protection Act 1998 (DPA) applies to dental records and
dental professionals must abide by its principles.
The DPA states that it is important that records are:
accurately created
carefully and securely maintained
disposed of appropriately.
The DPA also gives patients a right to access their records, both paper and
computer, including stored radiographs. Dental professionals can only limit or deny
access if, in their view, disclosure would:
be likely to cause serious harm to the physical or mental health or
condition of the data subject or any other person
give information about a third party, other than healthcare professionals involved
in the treatment, unless that other person consents.
If a patient asks to see their records, under Section 7 of the DPA they have a right to
access personal data held about them.
Dental professionals who control patient records are obliged to disclose a patients
dental record to that patient. Before doing so, they must have the patients written
request or have satisfied themselves of the authority of any person making a
request, if that person is not the patient.
Disclosure must take place as quickly as possible or in any event within 40 days
of receipt of the request. If the patient (or an authorised representative) wishes to
have copies, a fee can be charged currently up to 50 for hard copy records (or
a combination of hard copy and electronic) or 10 for electronic records to cover
reasonable copying charges.

Our advice
Dental professionals should publish
key points about the uses of patient
information and give information about
patients rights under the DPA in their
practice information material.

Checklist
Is a patients right of access to their
records outlined in your practice
literature?
Are all members of the dental
team trained in relation to their
professional and legal obligations
concerning clinical records?
When disclosing records to a
patient, have all named third
parties, other than healthcare
professionals involved in the
patients treatment, consented to
the disclosure?

Key points
1. Patients must be told of, and consent to, information being recorded about
them, including visual and audio recordings.
2. If a patient observes you making a note and co-operates with you to provide
information, that can be taken as implied consent but it is unlikely to be sufficient
for wider information sharing.
3. Patients should be told what will happen to the data you hold about them,
including when and how it is destroyed.
4. Patients and their authorised representatives have a right to access their
records.
5. There is a statutory 40-day disclosure period.
6. Hurt feelings or simple anxiety are not sufficient reasons to deny patient access
to the records.
7. You can charge for providing copies of patient records.

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4.4
Retaining and destroying records

Complaints and claims for clinical negligence can arise many years after
treatment and, in the absence of records, it may be difficult or impossible
to defend an allegation successfully.
The NHS General Dental Services contract (Schedule 3, part 5 paragraph 32)
requires the contractor to keep patient records for up to two years after a course of
treatment has finished.
Holding on to patient records for longer than two years may prove a vital part of your
defence should you receive a claim under the Consumer Protection Act 1998.
This Act allows claims in respect of defective products for up to 10 years and claims
in contract for up to six years.

Key points
1. As an absolute minimum, NHS and private clinical records1 should be retained
for:
a. 11 years after the last entry for adults
b. 11 years after the last entry for children or until they reach age 25 years,
whichever is the longer.

Our advice
We recommend that you retain patient
records longer than two years and
ideally, indefinitely. This includes
radiographs, photographs, study casts,
referral correspondence, investigation
reports and NHS forms.
If you do need to destroy records, be
sure that they are no longer needed for
dento-legal purposes. We recommend
that you indefinitely retain records
where there has been any adverse
incident or complaint, even if it was
satisfactorily resolved at the time.
Electronic records can be especially
difficult to destroy and we recommend
that you seek specialist IT advice.

2. The way in which you store your records should comply with a patients legal right
to confidentiality and your professional obligation to respect confidentiality.
The GDCs guidance Standards for the Dental Team (2013) paragraph 4.5.1
states: You must not leave records where they can be seen by other patients,
unauthorised staff or members or the public. (See section 2.1 Your obligations).

Checklist
Have you a safe and secure method
of storing your clinical records for
lengthy periods of time?

3. Record disposal should only be carried out in a way that protects patient
confidentiality e.g. shredding paper records.

Have you reviewed all records you

intend to destroy and kept those
involving any adverse incident,
complication or complaint?

Reference
1

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Records Management, NHS Code of Practice, Part 2 DoH (January 2009)

4.5
Patient rights

Patients have a right to access their records under the Data Protection
Act 1998 (DPA).
Ownership
NHS hospital and community dental service records are the property of the
appropriate trust or health board.
NHS General Dental Services (GDS) records are arguably the property of the
individual contractor and/or primary care organisation. NHS authorities have certain
rights of access to these records under NHS regulations.
Dental records for private patients are the property of the individual dental
professional or practice. The legal position of the ownership of private patients
radiographs is, however, uncertain. It can be argued the patient has paid for the
report or opinion from the radiograph, and not for the film itself. But patients may
claim that as they have been charged, the film is their property, even though the
dental professional may retain it with all the other elements of that patients records.

Access and accuracy

Patients have a right to access their records under the DPA. They are also entitled
to challenge the validity of records and to have factual errors corrected. (See section
4.3 Data protection legislation).

Key points

Our advice
If a patient insists on removing a
radiograph from the records, they
should be advised that they are then
responsible for the radiographs safekeeping. They should be informed that
if they lose it, any dentist treating them
in the future will not have the clinical
benefits of access to it. The fact that the
patient has taken the radiograph should
be recorded in the notes.
Any disagreement over factual matters
in the records should be noted, signed
and dated in the records.

Checklist
Is patients right of access to their
records outlined in your practice
literature?

1. Patient records, both private and NHS, are not the patients property. Patients are
not entitled to take possession of the originals.
2. Patients have a right under the DPA to view their original records and to have
copies of them.
3. A patient cannot stipulate the content of their records.
4. Dental professionals do not have to agree to requests for amendments or
deletions, except to correct a factual error.
5. An entry in the patients records should not be amended simply because the
patient does not like it.

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4.6
Record disclosure

Seeking patient consent to disclose any information about them is part of

a dental professionals legal and professional duty of confidentiality, and
important to the relationship of trust with the patient.

Our advice

Consent
If a patients identifiable personal data is to be disclosed, you must obtain their
express consent, preferably in writing, unless disclosure falls within one of the legal
exemptions where disclosure can be made without consent.

If information about a patient is to be

disclosed against their wishes, the
patient should be informed of this before
disclosure, unless this increases the risk
of serious harm or death to the patient or
others. Before releasing information, call
our dento-legal advice line.

Public interest
If a patient withholds consent to disclosure, is not competent to give or withhold
consent, or it is difficult to obtain, information may only be disclosed if it can be
justified as being in the public interest or the best interest of the patient e.g. where
the patient is at risk of significant harm. Dental professionals should document their
efforts to obtain consent and their reasons for disclosing information, which should
be the minimum needed for the purpose.

If a school asks for confirmation that

a pupil has booked or attended dental
appointments, you should not disclose
this information without the appropriate
consent of the patient or parental
authority in the case of children who
are not Gillick-competent.

Children
Children aged 16 and over enjoy the same rights of confidentiality as adults. The
confidentiality of Gillick-competent1 children, who are capable of understanding the
significance of disclosure of their records, should also be respected, though they
should be encouraged to involve parents or guardians. (See section 3.10 Consent
and children under 16).

If disclosure is considered necessary to

protect the patient or members of the
public from a risk of serious harm or
death, you should consider the possible
harm to the patient, and patient-dentist
relationship, against the benefit of
releasing the information.

Deceased patients
The duty to respect patient confidentiality extends beyond a patients death.
Information, such as dental chartings and radiographs, can normally be disclosed to
help identify a deceased patient as this would be justified as in the public interest.
Otherwise, authority will need to be obtained from an executor of the patients will,
personal representative or next-of-kin. Anyone with a claim arising out of a patients
death may be entitled to see the patients dental records under the Access to
Health Records Act 1990. (See section 2.1 Your obligations).

Checklist
Before disclosing any confidential
information, do you have the
patients consent to disclosure,
preferably in writing?

Third parties
Dental professionals may be asked to disclose a patients dental records, and/or
submit a formal written report (see section 5.4 Professional witness dental reports)
to certain individuals and authorities. These include relatives and carers, other
healthcare workers, NHS bodies, social services, the police, solicitors, the courts
and other tribunals. The principles of patient confidentiality apply and generally
the patient will need to give consent. (See section 2.2 Releasing confidential
information).

Key points
1. Full, and preferably written, consent is required for all disclosures of identifiable
personal data unless disclosure is in the public interest or the best interest of the
patient.
2. For consent to disclosure of records to be valid, the patient must understand:
a. to whom the information will be disclosed
b. precisely what information will be disclosed
c. the purpose of the disclosure
d. the significant foreseeable consequences
e. that relevant information cannot be concealed or withheld, except in
exceptional circumstances.
f. children aged 16 and over, and Gillick-competent children, enjoy the same
rights of confidentiality as adults
g. the duty to respect patient confidentiality extends to deceased patients.

Reference
1

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Gillick v West Norfolk and Wisbech AHA (1985) 3 All ER

402-437

Member call
Can I alter the records?

Our response

In this case, you are not in a position to

know the circumstances that led your
predecessor to make this entry in the
records or to assess the nature of the
dentist-patient relationship. It would be a
good idea to discuss with the patient why
he feels the entry requires amendment
but you should exercise extreme caution
before agreeing to make any alteration to
a record.

A patient is entitled to challenge the

accuracy of records and to have any
factual errors corrected under the
Data Protection Act 1998 (DPA).
However, you are not obliged to
amend an entry simply because a
patient does not like it.

In general, it would be inappropriate to

alter an entry made by a colleague. You
can however offer to include the patients
comments alongside the entry. Make it
clear to the patient what you can and
cannot do and ensure you keep a note of
the discussion for the record.

I have taken over the patient list

of a retired dentist at my practice.
One of my new patients has asked
me to delete an entry in his dental
record. The entry says the patient
has not been following the dentists
instructions but the patient says this
is not true. What should I do?

When factual errors do need to be

corrected in paper dental records,
strike through the entry with a single
line and insert the correct information
alongside. This should then be dated and
signed legibly. Due to the variability of
computerised record systems, we would
recommend making an entirely new entry,
correcting the previous one.

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