Uniformity in patient's treatment records is an important prerequisite for providing
optimal oral health. IDA has therefore drafted guidelines for maintaining records
which would result in good dental practice.
The dental records should reflect accurately the interaction between patients, clinicians and any related services.
Entries should be made without delay of all the events worth recording.
The following basic information should be maintained in all patient records. This includes:
Accurate general patient information which includes the patient’s full name, address and contact details. It should also include the time and date of the patient’s visit.
A detailed record of the patient’s medical history should be made. The practitioners should be satisfied that the information is correct. This information is sensitive and should not be made available to those who are not involved in the clinical care of the patient.
A detailed medical history form can be made available for the patients.ss
Before the formal first clinical examination, the dental history should record details of previous analgesia/anaesthetics, any oral allergic reactions not recorded in the medical history, previous dental experience, including the most recent and any other information the patient volunteers to give. Patients should be questioned with respect to:
A detailed record should be made for the reasons why the patient’s needed the dentist. The record should be made in patients own words as far as possible. Accurate description of the pain, known lesions or any conditions present on initial examination or mentioned by the patients should also be noted.
A record of a thorough clinical extra and intra oral examination. The method of recording may be standardised using diagrammatic charts or examination forms to allow rapid and simple comparison in the future.
Any existing radiographs should be viewed for usefulness in diagnosis and the need for further radiographs and any other special tests should be recorded together with their results. Last, there should be a short summary of observations and comments pointing towards a differential and definitive diagnosis.
It is important that all the radiographs are maintained in order. Both pre and post treatment radiographs should be preserved along with the radiograph report.
A written treatment plan should be constructed and maintained by the dental practitioner and a copy of the plan should be given to the patient. Records, radiographs, models, photographs and clinical details should be retained by the practitioners for a minimum period of eight years.
The treatment plan should include the proposed method for dealing with the patient's dental problems and describe the anticipated outcome of treatment. It should also include the materials, drugs and a brief description of the treatment procedure. Alternative treatment plans should be discussed and noted together with reasons for selection or rejection.
It should also be noted that definitive treatment may be influenced by the success of the initial phases of treatment and further patient co- operation in the post treatment phase.
Any need for referral for specialist assistance should be recorded.
Patients should be given the most appropriate treatment options along with the options for alternative treatment procedures. Patients consent to treatment should be obtained and noted. The treatment plan should be signed by the patient indicating their acceptance. Patient's refusal for accepting the recommended treatment should also be recorded.
The patient should be given complete details of the total expenses involved in the treatment procedure. Where a patient fee is due, this should be recorded.
It is very important that an accurate financial record is maintained along with the details of date, time and the mode of payment.
Patients have a right to expect that their personal information shared in the course of their health care will not be disclosed without their knowledge. The duty of confidentiality is towards all patients, including mature and immature minors and adults who lack the capacity to take decisions for themselves. Non- disclosure is held valid even after the individual's death. There are many instances when confidentiality can be breached unintentionally, such as leaving a message with a third party about the patients appointment with the dentist or discussing personal information in the waiting room in front of other patients.
The treatment record is a dynamic document that will record the progress of an individual and any subsequent course or courses of treatment.It must include:-
A differential diagnosis should be recorded. Full details of the anaesthetic and analgesic used should be recorded including the drug name, dose and site of administration, any adverse reaction should be noted. When the entire treatment plan is completed, there should be a final summary and conclusion indicating the prognosis along with the patient instructions for continued care and recall.
It is difficult to maintain a standard record keeping format which can be accepted internationally. Dental records contain both clinical and personal details. Such records simplify both the future treatment and satisfy the legal requirement of record- keeping. Ideally records should be retained on a permanent basis. The Indian Dental Association recommends that the records, radiographs, models, photographs and clinical correspondence should be securely retained for at least the legal minimum period of eight years.
Patient examination requires categorizing the patients in various subgroups. The subgroups of patients are new patients, recall patients, unscheduled patients and patients requiring referral.
Let the patient describe any symptoms or other abnormalities experienced, then carry out intra-oral and extra-oral examinations for signs of abnormalities and give appropriate treatment.
A recall patient must be given additional encouragement to maintain their oral health and motivation to revisit the dentist. Patients must be seen at proper intervals on the basis of their risk-level. During recall the patient must be motivated to manage or modify an oral habit which leads to poor oral health.
Patients in pain or in emergency should be promptly diagnosed and treated. The complete treatment procedure must be explained to the patient in order to prevent the reoccurrence of the problem.
Accurate information must be sent to the concerned practitioner. A referral letter should contain the diagnosis details and the treatment procedure selected by the referring practitioner.