Providing an excellent quality of Dental care with high standards of the oral treatment for the patients should

be the first goal for all dental clinics. To achieve that degree of dental care quality the dental practitioners should be able produce and maintain accurate dental records. The dental records are the most basic clinical toolin the process of dental care which is helping practitioners to obtain accurate and clear picture of the patient history and allow for appropriate continuity of care and provide for correct sequence of treatment. In this essay, I will discuss the importance of clinical records and its effects on our work. Furthermore, what are the elements that should be written in the dental records? In addition, how can the dentists obtains accurate and defensible dental records? Hence the clinical records importance will be critically discussed and the questions will be answered in this essay.

Comprehensive and accurate clinical records are essential in dentistry. Charangowda, B. (2010) demonstrates that good record keeping is fundamental for good clinical practice and is an essential skill for practitioners. Clinical records are extremely important for multiple reasons. The primary purpose is to provide a high quality dental care and follow up. Furthermore, dental audit which is essential aspect in clinical governance is heavily depends on what is recorded in dental records. Good records facilitate the process of dental audit (Irland, R., Harris, R. and Pealing R. 2011). Secondly, dental records also facilitate communication and this is largely important in the dental field where numerous dental practitioners treat patients over a given time frame. Pullen, I. and Loudon, J. (2006) show that clinical records help doctors to communicate with others doctors, with other health care professionals and with themselves.Thirdly, dental records considered as an official document in malpractice suits and this will help to determine the standard of diagnosis and treatment which was given to the patient. Andrew, R., Ban, J. and Playle, R. (2011) report that good records facilitate good defense, poor records a poor defense and no records no defense. Fourthly, identification of dead or missing persons can be obtained by using dental records which may provide appropriate information to the legal authority. Young dentists, female dentists and specialists are those most likely to keep complete and accurate records (Pessian, F. and Beckett, H. 2004).

The dental records should containing more than just clinical notes, they may contain study cast, photograph, radiograph and referral correspondence and investigation reports. Morgan, R. (2001) suggests that the dental records should contain all the following elements:

y y y y y y y y y y

Patients personal details, to include name, address, date of birth, gender and contact telephone number. Medical and dental history, to include alerts, precautions, current treatment and general medical practitioner information. This should be regularly updated. Examination of the dentofacial area and oral mucosa, including cancer screening. An initial dental examination, including periodontal status, restoration, caries, appliances, basic occlusion and any necessary radiographs, with written report. Sequenced treatment plan, together with any changes. Signed and dated notes at each visit, to include details of treatment, drugs administrated and prescribed (including local anaesthetic) and advice given. A valid consent process, at whatever level required. Any treatment declined by the patient should be recorded. Additionally, a procedure for the archiving and storage of non-active patient records should be present. Practices using computers for any part of the records must be registered with the data protection registrar.

National Health Servicedescribes a simple twelve procedure to ensure that your records are adequate: 1. Use a consistent style for entries, by using the same color and type of pen, same abbreviation and notations and so on. 2. Date and explain any correction, unexplained correction can be considered as a doctrinaire in dental records and can be used against the dentist in a malpractice cases. 3. Use single line cross out, integrity of the records is preserved by this way and give indication that you have nothing to hide. 4. Do not use correction fluids, may indicate that there has been an attempt to hide information. 5. Use ink, close up the questions of whether or not the records have been altered. 6. Write legibly, to prevent any guesswork by others and this may not favorable to you. 7. Express concerns about patient need, this indicates that you have listened, empathized, understood, and acted upon the wishes of your patient. 8. Never write derogatory remarks in the record. 9. Document fully, any missing information may can be used against you so detailed explanation is better than missing information.

10. Only use accepted abbreviations for treatments, helpful when transferring records to a different dentist or in a malpractice situation. 11. Collate documents, any material from third parties should be separate from those items that pertain directly to patient care. 12. Maintain a chronological order, the use of metal retainer and hole punch on the top of record are important to keep loose sheets organized.

The dental records should be retained as long as we can but it is impossible because the space constraints. After many years of treatment a complaints and claim for clinical negligence can be arise so it is impossible to defend the allegations if the records are absence. Records should be retained for: y y 11 years after the last entry for the adults. 11 years after the last entry for the children, or until they reach age 25 , whichever is the longer.

In conclusion, this essay shows that the importance of production, retention and release of accurate dental records as it an essential part of general practitioner responsibility. Good dental records should contain several elements that give accurate picture about patient case. The dental record should be written in professional manner that assist the dentist in medicolegal claim and can assist the police and coroners in the correct identification of individuals. Finally, good clinical records play an important role in producing good clinical care.

List of references: Andrew, R., Ban, J. and Playle, R..(2011). A comparison of computer- and handgenerated clinical dental notes with statutory regulations in record keeping.European journal of dental education. 15 (0), 1-5.

Charangowda, B.. (2010). Dental records: An overview. Journal of forensic dental sciences. 2 (1), 5-10.

Ireland, R., Harris, R. and Pealing, R..(2001). clinical record keeping by general dental practitioners piloting the denplan 'Excel' accreditation programme.British dental journal.191 (5), 260-263.

Morgan, R..(2001). quality evaluation of clinical records of a group of general dental practitioners entering a quality assurance programme.British dental journal.191 (8), 436441.

Pessian, F. and Beckett, H.. (2004). record keeping by undergraduate dental students: a clinical audit. British dental journal.197 (11), 703- 705.

Pullen, I. and Loudon, J.. (2006). improving standards in clinical record-keeping. Advance in psychiatric treatment. 12 (0), 280-286.