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Clinical Record Keeping in Dental Practice

1. Why the record is part of the treatment

2. What a colleague needs to read

3. Corrections, access and the screen behind you

Clinical Record Keeping in Dental Practice – Assessment

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Clinical Record Keeping in Dental Practice – Assessment

Clinical Record Keeping in Dental Practice
Clinical Record Keeping in Dental Practice – Assessment

Answer all questions. Pass mark: 80%.

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Question 1 of 8

1. Question

A clinical record is mainly for:

Decorating the server
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Continuity of care, the patient, and professional accountability
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Only CQC inspectors
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Marketing
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Question 2 of 8

2. Question

If advice was given but not written, the practical problem is:

Nothing, memory is perfect
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It is hard to show later what was said and when
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GDC bans all notes
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Reception can invent it next year
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Question 3 of 8

3. Question

Copied-forward templates are a risk when:

They are edited to match this visit
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They leave identical findings that were not actually checked
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They include the date
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A nurse uses them
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Question 4 of 8

4. Question

A telephone call about facial swelling should be:

Left on a sticky note
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Recorded as a clinical contact with advice and safety-netting
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Ignored if it is after 5pm
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Posted in a staff meme group
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Question 5 of 8

5. Question

If you add to the notes later you should:

Backdate so it looks live
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Mark it as a later addendum with date, time and reason
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Delete the original
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Use a colleague’s login
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Question 6 of 8

6. Question

Screens and records should be:

Visible to the full waiting room
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Locked when unattended and not shared out of curiosity
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Photographed for Instagram
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Emailed from a personal account ‘to be helpful’
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Question 7 of 8

7. Question

When a patient asks for a copy of their records you should:

Tidy away awkward entries first
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Follow the practice access procedure and current data-protection rules
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Refuse because dentists own the notes absolutely
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Charge a cash-only fee on the spot with no process
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Question 8 of 8

8. Question

This PrismCPD course is:

1 hour, standalone
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A replacement for Information Governance 1 and 2
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Legal advice on a claim
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Only for dentists
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