Writing Factual, Respectful and Understandable Notes

Patient records should be clear, factual and respectful. They may be read later by other dental professionals, the patient, regulators, solicitors, complaints teams or safeguarding staff. The entry should explain what happened without judgemental language, gossip, sarcasm or unclear shorthand.

Factual writing is especially important when emotions run high. Patients may be distressed, angry, frightened, confused or embarrassed. Record relevant behaviour or speech by describing what you observed or what was said, rather than attaching labels.

More professional wording

• Instead of "difficult patient", record the facts, for example "patient raised voice and said they did not understand the cost".
• Instead of "non-compliant", record the discussion and the patient's decision.
• Instead of "bad oral hygiene", record the clinical findings and the advice given by the clinician.
• Instead of unexplained abbreviations, use wording that another team member can understand.

Clarity prevents misunderstandings about care or required actions. Dental nurses can help by checking dates, names, batch numbers, tooth notation, appointment details, handover tasks and patient information leaflets where this falls within local procedure.

Patient access to records

Good records should be understandable, respectful and based on facts rather than assumptions.