SUPPLEMENTARY OUTCOME

APPENDIX I
Every practising dentist has a responsibility to maintain good quality clinical records. This has been
clearly stated by the GDC and also reinforced by bodies such as the BDA and GDPA. Clinical records
are fundamental to the process of the delivery of dental care, contributing to the diagnosis, planning
and correct sequencing of treatment. Moreover, accurate records are essential for ensuring that
patients receive appropriate and safe treatment.

1. List the reasons why taking of a general medical history by dentists is important:
Every practising dentist has a responsibility to maintain good quality clinical records. Clinical
records are fundamental to the process of the delivery of dental care, contributing to the
diagnosis, planning and correct sequencing of treatment. Moreover, accurate records are
essential for ensuring that patients receive appropriate and safe treatment.

List the reasons why taking of a general medical history by dentists is

important:

 It enables dentists to obtain information necessary to provide appropriate, individualised

care.
 A medical history helps to identify conditions relevant to the patient’s dental health or
which could have an impact on how treatment is carried out, e.g. cancer, leukaemia, AIDS
and organ transplant
 Drug allergies and interactions.
 Information about certain medical conditions such as diabetes, epilepsy, allergies or heart
disease which could be vital if a medical emergency occurs in the dental practice
 Recording smoking and alcohol units, which enable the dentist to identify and address risk
factors for oral cancer.
 Medical histories reveal critical information required to address infection control issues.
Despite the fact that cross infection control in dentistry is generally based on the principle
of ‘standard precautions’, in certain cases it is necessary to try and identify members of at
‘risk’ groups such those ‘at risk’ of developing iatrogenic Creutzfeldt-Jakob Disease (CJD).
 To prevent medical complications and thus minimise detrimental effects to the patient
and the possibility of medico-legal complications for the dentist.

2. Where should a medical history form be stored?

A medical history form should be present in the patients record card

3. When should a medical history form be updated?

At every recall
At the start date of a new course of treatment

4. When listing drugs what information is required?

Patients ID
Reason for prescription
Dose
6. Tutor feedback
This section should be completed by the GDC registrant who is assessing all sections of the completed PER
and is normally based at the Training Centre. Constructive feedback will help the student to develop their
performance in the workplace.

Satisfactory ☐ Not Yet Satisfactory ☐

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Internal Moderation
Internal Moderator Name:
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Meets NEBDN Requirements: Yes ☐ No ☐