Patient records and information

For the safe, efficient and legal provision of care and treatment it is important that patient records are current, accurate, complete, logical, clear, concise, legible by anyone, and easily understood.

This policy outlines our system for the using, updating and storage of patient records (notes) and associated relevant documents which are needed to ensure a safe and reliable practice.

Charting notation

A full dental charting detailing teeth present, current restorations and their materials, caries, mobility, missing teeth and details of any prostheses should be recorded, agreed and checked with the nurse.

Patient notes

Patients’ notes are stored in secure and locked filing cabinets, notes are only removed when needed and we endeavour to replace it in filing cabinet as soon as they have been updated. There is separate filing system and locked filing cabinet for older archived notes. That is notes from patients that have not been seen in the practice for over 11 years.

Confidentiality

Our privacy and confidentiality statement is displayed prominently, given to all new patients, printed and online, their acceptance is required as part of the registration process.

Its purpose to demonstrate the importance we give to respecting the privacy of our patients and confirms our commitment to only use their data for the purposes of their care and treatment and not shared with anyone else or sold to 3rd parties.

For further information on the data protection act 1998 a copy can be found in our HR Manual which covers the rights of staff as well.

Data protection policy

In our busy practice we are continually transferring information and data, both on an internal network (LAN) and via our secure internet CRM system with dedicated server (UK based). Occasionally information is sent or transmitted to external providers, mostly referrals or lab work; therefore it is essential we are vigilant in protecting our patients’ personal information and data and reduce risk of data loss with regular back-ups.

We comply with the Data Protection Act 1998 this policy describes our procedures to ensure patients personal information is processed whilst maintaining their confidentiality and protected and not accessible to unauthorised individuals.

The practice is registered with the Information Commissionaire Officer and we aim to ensure that the recommended measures are in place in order to protect confidential information that we are holding on patients’ records both paper and electronic.

In order to provide our patients with a high standard of dental care and attention, we need to hold personal information about them.  This personal data comprises:

  • their past and current medical and dental condition; personal details such as age, address, telephone number, occupation and general medical practitioner
  • special requirements and language or translation needs
  • radiographs, clinical photographs and study models
  • information about their treatment that we have provided or propose to provide and its cost
  • notes of conversations/incidents that might occur for which a record needs to be kept
  • records of consent to treatment
  • any correspondence relating to them from other health care professionals
  • statement from the laboratories

Patient data is held in the practice’s computer system and/or in a manual filing system. The information is not accessible to the public and only authorised members of staff have access to it.  Our computer system has secure audit trails and we back up information routinely.

Unless otherwise required as part of your normal duties staff must never disclose any confidential information to any person. Ensure that all documents containing confidential information are either locked away or shredded where no longer required at the end of the working day or if you are due to leave your work area/chair for any length of time.

Disposal

In order to dispose of paper, documents, and old day lists we normally use an office shredder however in case of a backlog and large volumes of sensitive documents we occasionally use professional data shredding services.