Record keeping

Refer to Section 9 of the full guidance.

Good record keeping underpins the provision of quality patient care.

Increasingly, the care of patients is shared among dental team members and between other professionals. Therefore, it is important to practise good record keeping to ensure that all relevant information is available to facilitate the provision of effective, long-term shared care of patients.

If carried out consistently for each patient, it will also save time in the long run for the dental team and will provide a permanent record of the care provided, which is essential for medico-legal reasons.

  • Record in the patient’s notes:
    • specific periodontal complaints e.g. bleeding gums, loose teeth
    • self-reported oral hygiene habits
    • the results of the BPE and the standard of oral hygiene
    • the results of the full periodontal examination (if performed)
    • a provisional diagnosis and follow up with a definitive diagnosis once any special investigations have been performed
    • the suggested treatment plan and details of costs
    • the details of any treatment
    • the details of any discussions of oral hygiene (using Oral Hygiene TIPPS), smoking cessation or other lifestyle factors and, where appropriate, record compliance with advice given
    • details of referrals
    • the appropriate recall interval
  • Document the discussion of the options, risks and benefits of treatment, including the ‘no treatment’ option. If treatment is declined, record this in the notes.