How do we make patient As part of a comprehensive dental record system, you Standardised templates or forms for patient dental dental records available to should have electronic or based patient dental records, either electronic or paper based dental practitioners and other records available where dental care or treatment is List of agreed standard abbreviations used by dental team members when care provided. The patient’s dental record should be practitioners and other team members providing care is provided? available to the dental practitioner or other team Policy, procedure or protocols for filing investigation members providing care in the treatment room so that results and clinical correspondence in the dental How do we know our patient all aspects of dental care can be record system dental records are documented, including: System for the retrieval of current and archived comprehensive and accurate? patient dental records medical history Audit of availability of the patient dental record at the correspondence from other healthcare professionals time it is required for use by the dental practitioner or examination and test results other team member providing care radiographs Other: photographs treatment options treatment plan the informed consent process. You should use standard abbreviations to ensure that other members of the dental team can understand patient dental records. The design of the patient clinical record allows for systematic audit of the contents against the requirements of these Standards Reflective questions Suggested strategies Evidence examples How do we know our patient You should ensure that: Results of dental record keeping audits dental records are meeting the Evidence of changes to the patient dental record the patient’s dental record is designed so as to allow key requirements of system that improves its auditability for clinical the logical flow of information about the treatment standards? information and care provided List of agreed standard abbreviations used by dental the flow of the information in the history is ordered so practitioners and team members providing care that an external or inspection can easily follow Other: the actions of the dental practitioner or other team member providing care during the examination and treatment phases the record is completed and recorded in a consistent manner by the dental practitioners working within the dental practice
How do we make patient dental records available to dental practitioners and other team members when care is provided? How do we know our patient dental records are comprehensive and accurate? As part of a comprehensive dental record system, you should have electronic or based patient dental records available where dental care or treatment is provided. The patient’s dental record should be available to the dental practitioner or other team members providing care in the treatment room so that all aspects of dental care can be documented, including: medical history correspondence from other healthcare professionals examination and test results radiographs photographs treatment options treatment plan the informed consent process. You should use standard abbreviations to ensure that other members of the dental team can understand patient dental records. Standardised templates or forms for patient dental records, either electronic or paper based List of agreed standard abbreviations used by dental practitioners and other team members providing care Policy, procedure or protocols for filing investigation results and clinical correspondence in the dental record system System for the retrieval of current and archived patient dental records Audit of availability of the patient dental record at the time it is required for use by the dental practitioner or other team member providing care Other: The design of the patient clinical record allows for systematic audit of the contents against the requirements of these Standards Reflective questions Suggested strategies Evidence examples How do we know our patient dental records are meeting the key requirements of standards? You should ensure that: the patient’s dental record is designed so as to allow the logical flow of information about the treatment and care provided the flow of the information in the history is ordered so that an external or inspection can easily follow the actions of the dental practitioner or other team member providing care during the examination and treatment phases the record is completed and recorded in a consistent manner by the dental practitioners working within the dental practice Results of dental record keeping audits Evidence of changes to the patient dental record system that improves its auditability for clinical information List of agreed standard abbreviations used by dental practitioners and team members providing care Other:
NSQHS-Standards-Guide-for-Dental-Practices.docx