Patient Records: What does good look like?

Clinicians have an ethical obligation to keep a detailed contemporaneous record of the care and treatment provided. Clinicians should ensure they follow guidelines issued by the FGDP(UK) in their standards guidance.

This course outlines what should be recorded at all clinical examinations and the interventions required to be undertaken in clinical practice.

This course is suitable for the whole dental team.

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Patient records: What does good look like?

A good dental record will provide the reader with a clear chronology of the treatment the patient received as well as details of the various discussions that took place during treatment planning and the consent process.

Poor record keeping can leave the whole clinical team (not just the clinician) vulnerable if a complaint arises. Poor records also make it difficult to deliver a high standard of clinical care because they lack essential details.

Dentists have an ethical obligation to keep a detailed contemporaneous record of the care and treatment provided.

This course aims to help you understand and implement good dental records for all clinical examinations and interventions in clinical practice.

You will understand what to record for:

  • New patient examinations
  • Recall patient examinations
  • Periodontal examinations and treatment
  • Fillings
  • Crowns, bridges, veneers and inlays
  • Endodontic treatments
  • Extractions and surgical procedures
  • Sedation
  • Implants
  • Orthodontic treatment
  • Dentures
  • Tooth whitening
  • Sports mouth guards and night bite guards.

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Course Curriculum

  • Why is good record keeping important?
    5 minutes
  • GDC Standards
    5 minutes
  • Care Quality Commission and NHS requirements
    5 minutes
  • What information should be recorded?
    5 minutes
  • Faculty of General Dental Practice (UK) FGDP (UK)
    5 minutes
  • Personal information
    5 minutes
  • Medical History
    5 minutes
  • Social, behavioural or family history
    5 minutes
  • Previous dental history
    5 minutes
  • Reason(s) for attendance
    5 minutes
  • Clinical examinations and recording
    5 minutes
  • Extra-oral clinical examination
    5 minutes
  • Intra-oral clinical examination
    5 minutes
  • Caries and periodontal disease risk assessments
    5 minutes
  • Radiographs
    5 minutes
  • Special tests
    5 minutes
  • Differential diagnosis
    5 minutes
  • Discussions and advice given
    5 minutes
  • Treatment plan
    5 minutes
  • Types of written treatment plan
    5 minutes
  • Bespoke written treatment plans
    5 minutes
  • NICE guidance and the recall examination
    5 minutes
  • Periodontal records
    5 minutes
  • Demonstrating consent
    5 minutes
  • Local anaesthetic
    5 minutes
  • Fillings
    5 minutes
  • Crown, bridge, veneer or inlay
    5 minutes
  • Endodontic procedures
    5 minutes
  • Extraction
    5 minutes
  • Surgical procedure
    5 minutes
  • Implants
    5 minutes
  • Sedation
    5 minutes
  • Dentures
    5 minutes
  • Orthodontic records
    5 minutes
  • Capture and record essential information
    5 minutes
  • Using templates to record information
    5 minutes
  • Summary – Patient Records
    5 minutes
  • Pre-Question Advice Preview
    1 minutes
  • Patient Records – What does good look like?
    8 questions
  • Feedback & Reflective Learning Guidance
    5 minutes

Your course includes

 

Up-to-date information

Our course material is both current and relevant; verified by leaders in the dental industry.

Various media

We use a combination of text, imagery, videos and presentations to help you get the most out of this course.

Course downloads

This course features documents for you to download and use in your dental practice.

Post-course feedback

Upon completion of the course you are required to complete a short feedback survey.

Post-course feedback

Upon completion of the course you are required to complete a short feedback survey.

Frequently asked Questions

When does the course start and finish?

The course begins when you are ready. Although the course duration is 60 minutes, you can work at your own pace, and your progress is saved automatically.

How long do I have access to the course?

After registering for the course, you have 365 days to access the course.

Does the course have a test?

Yes. There is a short assessment at the end of the course. You must achieve 80% or more to pass the course. If you do not pass, you have the opportunity to review the content and re-take the assessment when you are ready.

Does the course offer a certificate upon completion?

Yes. Upon successful completion of the course, you will be awarded a personalised certificate. This is saved to your personal dashboard. You can download and print this certificate when you require it. In addition, you are also credited with a digital badge that will feature in your personal dashboard.

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