Records, Handover, and Speaking Up

Good consent records should document the decision-making process as well as the outcome. Dental nurses contribute through notes, chairside observations, handover to the dentist, reception messages, interpreter records, updates to medical history, or documentation when a patient asks to pause.

Useful consent-related records may include

• Questions, concerns, preferences, or misunderstandings raised by the patient.
• Communication support used, such as an interpreter, Easy Read material, or extra appointment time.
• Changes in consent, clear stop signals, signs of distress, or withdrawal during care.
• Who was informed, what was escalated, and the agreed next steps.
• When relevant, written consent forms and clinical notes from the treating clinician.

Write records that are factual and respectful. Avoid judgemental terms like "difficult", "non-compliant", or "refused to cooperate" when the issue is anxiety, pain, disability, misunderstanding, or lack of information. If a patient raises a concern after the dentist has left, record their words and pass the information on through the correct route.

Speaking up can feel difficult, especially where there is a power imbalance with a dentist, owner, or senior colleague. Prepare short, professional phrases such as: "Can we pause? I am not sure the patient has understood", "The patient has just asked us to stop", or "This sounds like a new option or cost change; should the dentist explain it before we continue?"

Governance, regulation, and escalation

Clear records and respectful speaking up protect patient autonomy. Consent concerns are patient-safety concerns.