Records, Follow-Up and Written Responses

Reliable records are essential for candour and for handling complaints. They show what was known, what was said, what action was taken, and who was responsible for any follow-up. Good records also allow the practice and staff to review decisions later.

Record facts rather than judgement. Note what the patient said, what you observed, what you did, who you informed and what was agreed. Do not rewrite history, alter notes to make an incident look better, or add defensive comments the patient might find upsetting.

Useful factual details

• Date, time, place and people involved.
• The patient's own words where relevant.
• Any immediate clinical or safety action taken.
• Who was informed and when.
• Any apology, explanation, leaflet or route given.
• Follow-up owner, date and contact method.

Written replies to complaints are usually prepared by the complaints lead or clinician, but dental nurses may supply factual details. Responses should be clear, respectful and address the points raised. If the investigation will take longer, the patient should be kept informed.

Clinical records and complaint records

Factual records support candour. Defensive or judgemental notes can damage trust and make later review harder.