Dental Recordkeeping Guidelines

Dental Recordkeeping Guidelines

• The British Columbia College of Oral Health Professionals (BCCOHP) was formed in 2022 via the amalgamation of previous oral health regulatory colleges.
• BCCOHP protects the public by ensuring oral health professionals practice competently, setting standards for safe and patient-centered care, and investigating complaints.
• Dental records must be accurate, well-organized, legible, accessible, and understandable.
• A complete patient record documents all aspects of dental care ensuring continuity and comprehensiveness.
• This information is to aid the practitioner or another practitioner in continuing care should the original one become unable to continue.

Practice Guidelines

• The College of Dental Surgeons of BC (CDSBC) guidelines for dentists and certified dental assistants aid patient care.
• Practitioners are responsible for accurate patient records.
• Records should be used for evaluating professional responsibilities.

Contents

• Introduction
• Medical and Dental History
• Confidentiality
• Dental Examination
• Informed Consent
• Treatment Records
• Electronic Record Keeping
• Financial Records
• Drug Records
• Ownership, retention, transfer, and disposition of dental records

Introduction (Page 3)

• Professional, ethical, and legal responsibilities require complete charts.
• Guidelines provide assistance and comfort to the public that dental patient information is both accurate and confidential.
• Records management is critical, regarding documentation, information release, and storage.

Medical and Dental History (Page 5)

• Includes a review and initial by the treating practitioner.
• Updated regularly based on the patient's age and history.
• Needs to include all illnesses, conditions or adverse reactions, respiratory diseases, allergies, and medications.
• A pertinent medical history is necessary to provide safe dental care.

Confidentiality (Page 6)

• Records must be confidential and protected from unauthorized use or disclosure (except where legally required).
• Shared with other health professionals only with patient consent.
• Staff must be trained to maintain confidentiality.
• Records should be stored securely.

Dental Examination (Page 7)

• Should include vital signs if treatment warrants them.
• Should include periodontal evaluations.
• Should reflect initial conditions.
• Record changes in clinical findings during subsequent examinations.
• Extra-oral evaluation, soft tissue evaluation, and dentition evaluation.

Radiographs and Dental Records

• Records must be properly labelled, dated, and of acceptable quality.
• Radiographs could require retakes, and issues to consider for low-quality images are provided.
• Radiographs should record conditions, number, and types.

Diagnosis and Treatment Planning (Page 8)

• Records should note any immediate needs/complaints.
• Should discuss the overall condition of teeth and supporting structures and be regularly reviewed.
• Records should have notes on caries risk and periodontal status.

Informed Consent (Page 9)

• Based on the patient’s right to decide what happens to their body.
• Consent should be obtained for risks, benefits, and costs of treatment.
• Consent can be implied or expressed (oral or written).
• In cases of emergency, or if the patient is impaired, informed consent may not be necessary.

Treatment Records (Page 10)

• Progress notes should comprehensively record care, reasons for treatment, discussion of limitations, and consultation documents or recordings.
• Records must include dates, clinician’s identity, area/tooth treated, diagnosis, any administered or prescribed medication(s), and treatment options, alternatives and outcomes.

Electronic Recordkeeping (Page 11)

• Electronic records must follow the same guidelines as paper records.
• Electronic records must have an audit trail.
• Needs to provide visual display, retrieval, and printing of information.

Financial Records (Page 12)

• Includes details of financial agreements with patients/guardians, fees charged, and payment records.
• Includes commercial laboratory costs, and copies of all dental claim forms.

Drug Records (Page 13)

• Dentists must protect controlled substances.
• Required documentation (including date, drug, dosage, etc.) must be on prescription pads and the register.
• Records must show a reason for receiving drugs, as well as handling procedures.

Ownership, Transfer & Disposition of Dental Records (Page 14)

• Dental practice generally owns the patient charts unless otherwise agreed. In case of selling/transferring, outgoing dentists must notify patients.
• Retention of records is dictated by the Limitation Act.
• Retention varies based on the date of the last entry.

Release and Transfer of Records (Page 15)

• Patients have the right to access their records.
• Records transfer between practices should be within a reasonable timeframe.
• Dentists can charge reasonable fees for copies.

This quiz covers the essential guidelines for dental recordkeeping as set by the British Columbia College of Oral Health Professionals. It emphasizes the importance of maintaining accurate, organized, and accessible patient records to ensure safe and continuous dental care. Practitioners are responsible for adhering to these standards to promote patient-centered care.