“GDC state you must make and keep contemporaneous, complete and accurate patient records”

Dental record keeping has changed significantly over the last number of years due to regulatory amendments and advancements in technology. Dental records are an essential clinical tool for dental professionals. The purpose of dental records is to provide an accurate picture of patient treatment and care which can be used at every consultation. We have helped more and more clinics transition frompaper records and move to digital practice management software and we expect this to increase with GDPR regulations becoming more prevalent.

The four C’s guide to completing clinical notes

  1. Contemporaneous– recording of notes should be made at the time of treatment or as soon as possible after treatment.
  2. Clear– records should be easy to read and carefully written, so they can be understood by anyone who needs to read them.
  3. Concise– notes should be to the point with the essential information regarding the treatment.
  4. Complete– every patient’s visit should be recorded with the relevant information relating to the visit.

Having a cloud dental software can help to record notes, store the information and provide a printable hard copy if needed, ensuring you are compliant with dental record keeping legislation. It will also give you online secure access to clinical notes to help you access them at any time.

How Cloud Software can help keep your notes compliant

  1. Stores records securely ensuring you comply with GDPR
  2. Data is backed-up making sure you never lose any information
  3. Clearly identifies the author
  4. Gives a date stamp of notes recorded
  5. Locks down notes to prevent editing on a later date
  6. Allows the author to use note templates to help with note taking
  7. Ensures you have an audit trail of written notes

If you would like to find out more information on digital record keeping speak to one of our experts within the dental cloud technology sector today!