Dental Records

Code of Practice No: C003 [2007]

Issue date: July 2007 Next review date: July 2010
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PREAMBLE Purpose 1. This code of practice has been developed pursuant to section 118(1)(g) of the Health Professions Registration Act 2005 (the Act). Its purpose is to ensure that dental health practitioners maintain records that serve the best interests of their patients by contributing to the safety and continuity of their dental care. Scope 2. This code applies to all dental health practitioners with current registration under the Health Professions Registration Act 2005 (the Act) except for those who have been granted nonpractising registration under the terms of section 11 of the Act. 3. This code prescribes the minimum requirements for dental records whether they are in paper-based or electronic form. 4. There are a number of laws that have an impact on the keeping of health records and dental health practitioners must manage their dental records in accordance with both this code of practice and the requirements of state and commonwealth law. REVIEW 5. This code of practice will be reviewed and updated regularly to ensure that it accords with legislation, national and international standards and any relevant developments in the provision of dental care. INTRODUCTION Why make records? 6. A record of each patient visit is an essential part of the practice of dentistry. 7. Good dental records facilitate high-quality, comprehensive care by making detailed and relevant patient information (both current and historical) readily available to treating practitioners. 8. Accurate dental records assist in the efficient and complete delivery of care in the event of another practitioner assuming that patients treatment. Records also provide a means of continuity in documentation and patient care. 9. Dental records are useful for forensic purposes and can play an important role in the identification of deceased and missing persons. 10. Dental records can provide a repository of valuable information for teaching, education and research. 11. Dental records form the basis for retrieval of treatment details in the case of a dispute or the requirement to provide evidence. REQUIREMENTS 12. The following are the minimum requirements for dental records. This is, in the Boards view, the minimum standard required for public safety. 13. Dental health practitioners have a professional and legal responsibility to: (a) keep the information they collect and record about patients confidential; (b) retain, transfer, dispose of, correct and provide access to dental records in accordance with the requirements of the laws of the state and commonwealth; (c) assist patients to make well informed decisions about treatment procedures and not to force treatment on them without their consent. 14. In order to practise in a professionally responsible manner practitioners, while exercising their professional judgement in each particular situation, must maintain their dental records at a standard that satisfies the purpose of this code.
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Dental Records
Code of Practice No: C003 [2007]
Issue date: July 2007 Next review date: July 2010
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General principles to be applied 15. A dental record must be made at the time of the appointment or as soon thereafter as practicable. 16. Entries on the dental record must be made in chronological order. 17. Entries on the dental record must be accurate and concise. 18. Dental records must be readily understandable by third parties (particularly another dental health practitioner). (Third party access is subject to the application of the provisions of privacy legislation). 19. Dental records must be promptly retrievable when required. 20. Dental records must be stored securely and safeguarded against loss or damage. 21. All comments must be couched in objective, unemotional language. 22. Corrections made to records must not remove the original information. 23. The treating dental health practitioner must not delegate responsibility for the accuracy of medical and dental information to another person. Information to be recorded 24. The following information forms part of the dental record and is to be recorded and maintained, where relevant: Patient details (a) Identifying details of the patient. (b) Completed and up to date medical history. Clinical details (c) For each appointment clear documentation describing: (i) the date of visit (ii) the identifying details of the dental health practitioner providing the treatment (iii) information about the type of examination conducted (iv) the presenting complaint (v) relevant history (vi) clinical findings and observations (vii) diagnosis (viii) treatment plans and alternatives (ix) patient consent (x) all procedures carried out (xi) instrument tracking information (batch control identification), where relevant (xii) drugs prescribed or administered or other therapeutic agents used (name, quantity, dose, instructions). (d) Unusual sequelae to treatment. (e) Radiographs and other relevant diagnostic data. Other details (f) All referrals to and from other practitioners. (g) Any relevant communication with or about the patient. (h) Details of anyone contributing to the dental record. (i) Estimates or quotations of fees. NON COMPLIANCE 25. The Board will use the minimum standard described in this code of practice in evaluating the professional conduct of practitioners. Failure to comply with this code of practice may be considered unprofessional conduct.
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Dental Records
Code of Practice No: C003 [2007]
Issue date: July 2007 Next review date: July 2010
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BOARD PUBLICATIONS 26. The following Board publications are also relevant to record keeping and should be read in conjunction with this code of practice: (a) Information sheet I001: Dental Records. This document provides background information about record keeping and a Checklist to assist practitioners to self-audit their dental records; (b) Information sheet I002: Consent: Assisting patients to make well-informed decisions. The law of consent is summarized in this document. 27. The Boards documents are available on the website or by contacting the Board
see http://www.dentprac.vic.gov.au/

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