Why Clinical Records Matter
Clinical records form the foundation of patient care, continuity, and legal defence. In complaints or claims, records are often the primary evidence used to assess whether appropriate care was provided.
GDC Standards for Record Keeping
The General Dental Council requires records to be clear, contemporaneous, accurate, and sufficient to justify clinical decisions. Records should demonstrate consent, diagnosis, treatment planning, and follow-up care.
Common Record Keeping Failures
Frequent issues include missing consent notes, vague treatment descriptions, alterations without justification, and inconsistent documentation across clinicians.
Records and Dental Negligence Claims
In negligence cases, incomplete records often shift the burden of proof against the dentist. Well-maintained records can prevent claims from progressing.
Digital Records and Compliance
Digital record systems improve consistency but introduce GDPR and data protection obligations. Access controls, audit trails, and secure backups are essential.
Best Practice for Risk Reduction
Dentists should document discussions, risks, alternatives, and patient questions. Records should be updated immediately after treatment and reviewed regularly.