Moving to electronic record keeping

Dental records are essential clinical tools. Keeping an accurate – and contemporaneous and legible – patient record is important in ensuring the whole team follows good clinical practice. These will include:

Personal details

Medical history, including notes of medication/allergies

Clinical notes

Diagnostic information (radiographs and photos)

Signed treatment plans

Any correspondence

Laboratory information

NHS forms

Referral letters and so on.

With an ever-developing digital approach to dentistry, record keeping needs to support the diagnostic tools, the treatments and the equipment systems now available to patient care. However, the same dento-legal requirements apply to digital records as to manual records and, as computerised records rapidly become the norm, it is worth noting that the software chosen needs to have a built-in system to prevent ‘doctoring’ of the records at a later date. Your computer software should also be capable of producing a hard copy of records and radiographs and a full audit trail of record creation and modification. All patients' medical records should be updated at every appointment, with the computer keeping a log of when it was last updated. All computerised clinical notes will also need to comply with the Data Protection Act. They will need to be password protected and incapable of modification once the information is date stamped and electronically signed. This ensures clinical notes are contemporaneous and capable of an audit trail. The records will are also need to be protected against accidental loss, corruption and damage by regularly backing up the information. As part of any transition across to electronic record keeping, there is an obligation upon you to ensure old paper records are securely stored in lockable filing cabinets. As a dentist, you have a professional, ethical and legal duty to keep confidential all personal information gained about patients in the course of their professional relationship. You have a duty to protect the confidential data of your patients under the DataProtection Act (1998) and civil monetary penalties can be imposed for serious contraventions of the act. All businesses processing personal data should observe the Data Protection Principles to ensure that data is: