Keeping dental records is extremely important for any practitioner. In fact, it is a legal obligation for every dentist to keep clear record of their patients. Harold with Dental SCV clarifies, “Simply put, dental records are documents that tell the history of a patient’s oral health under a particular dentist’s care.” This article will explain how dental records are made, kept and why they are so important.
How Are Dental Records Made and Kept?
The number one rule about making dental records is that they must be informative and clear. You need to include detailed information about a patient’s clinical exam, diagnosis, treatment and prognosis. Include all the information you deem necessary about the patient’s current illness. Having a form to fill is an easy way to capture all the information that you need about a particular patient. Ideally, financial information should not be included in your dental records.
When it comes to keeping the records, you can choose whether to use a computer system or the traditional physical files. Keeping records in a computer database is more advisable as it is rather convenient. In fact, a survey that was conducted in the United States showed that 74 % of single practitioners and 78.4% of group practitioners kept their records in a computer. You should ensure that every time you enter a new record for a given patient, you sign and date the record.
Why are dental records so important?
Dental records are extremely important as they are a legal requirement of every dentist. Failure to keep and maintain clear records can land one in trouble. Additionally, they can be used in a dentist’s defense in case a suit of malpractice is brought against them.
The records are also important in assessing the quality of dental care that a dentist provides to his patients. A dentist who clearly documents every service they offer will be assessed with ease and more accurately. What is more, clear dental records can help another service provider quickly assess and serve a patient in case the primary dentist is away. This is also the case should the patient need to change dentists.
Additionally, dental records are important in forensics. They can be used to help identify a person whose DNA cannot be found, or one who has been missing for a long period of time. Dental records are also used to help solve crimes, and dentists are obligated to supply them to the National Crime and Information Center upon request.
Keeping and maintaining clear records is absolutely important for any dentist. Not only is it an ethical and legal requirement, but it also helps provide the best dental care to patients. Any respectable dentist should take it upon themselves to make, keep and maintain good records.