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Patient data and record keeping

Dental practices hold information about patients, staff and associates. As such, they must act to ensure that they comply with data protection laws.

​As a dentist working today, you should familiarise yourself with data protection legislation and how that impacts your practice.

 

NHS dental practices count as public organisations and therefore also need to appoint a data protection officer, who can be a practice manager or an associate. All members can access our online GDPR advice. Expert or Extra members can receive personalised one-to-one advice on data management and regulatory compliance.

 

If you’re an Expert or Extra member, you can get in touch with our expert advisers today by emailing advice.enquiries@bda.org or calling 020 7935 0875.

 

Record keeping

Good record keeping is central to good dental practice. Indeed, dentists are often first judged on the quality of their record keeping. Poor records can sometimes leave complaints and claims for damages indefensible. Don’t let time constraints hinder your efforts to record notes effectively.

 

Dentists must be aware that they are responsible for the acts and omissions of their staff, including information documented in the dental record, so it is essential that the following standards are adhered to:

 

  • Consistent management of records
  • Confidentiality
  • Quality assurance (for example, through audit)
  • Records are made contemporaneously
  • Care is taken that there is no risk of confusing two patients with the same or similar names
  • Patient notes are made only by people authorised to do so
  • Records are kept in a secure place; for electronic records take advice from an information technology expert and use appropriate safeguards
  • Patients are allowed to access to their records.