Keeping well-documented patient records is an essential part of the health care system, including dental practices. High-quality clinical notes are essential to:
? Record details of patient assessment and to produce a treatment plan (Faculty of General Dental Practice (FGDP), 2007)
? Record treatment details
? Act as a legal record where dispute exists
? Facilitate practice administration and finance processes.
Patient records are increasingly important, due to an increase in litigation arising from patient complaints (Moyes, 2014). A complaint may more commonly be directed at a dentist or dental care professional (DCP) than a dental nurse, but it is often the dental nurse who creates the record.
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