Why Timely, Complete and Accurate Records Matter

Patient records form part of clinical care. They show what has happened, what is planned, the risks involved and any support the patient needs. Clear records also help different members of the dental team provide consistent care.

Records should be contemporaneous - made at the time or as soon as possible afterwards. They should be complete - containing the information needed for safe care. They should be accurate - reflecting what happened and readable by others.

Good records help show

• Who the patient saw and what care was provided.
• Relevant medical history, medicines, allergies and alerts.
• What was discussed with the patient, including questions and concerns.
• What information, aftercare or written instructions were given.
• What follow-up, referral, review or handover was required.
• Any communication needs, reasonable adjustments or safeguarding actions.

Dental nurses may record information directly or pass it to the clinician or authorised record-keeper. If you notice information that could affect care, do not rely on memory - ensure it is recorded or passed on promptly.

Contemporaneous means timely

Good records are part of safe care. They should be timely, complete, accurate and useful to the next person caring for the patient.