Recordkeeping

Abstract

This best practice presents recommendations regarding recordkeeping for dental patients. The patient record is an essential component of the delivery of competent and quality oral health care. Electronic dental records are being adopted by more dental practices and may assist with quality and efficiency of health care. Data security and privacy of identifiable health information are important considerations in recordkeeping. The patient record allows the provider, the patient, and authorized third parties to access the history and details of patient assessment and communications between dentists and patients, as well as specific treatment recommendations, alternatives, and risks and care provided. This document provides dental professionals with guidance on several pertinent aspects of dental record-keeping including general charting considerations, components of a patient record, patient medical and dental histories, comprehensive and limited clinical examinations, treatment planning and informed consent, progress notes, correspondence and consultations, records transfer, corrections to records, retention of records, and patient access to their health records. The scope of information to include and formatting for consistency and ease of interpretation are addressed.

This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs and Scientific Affairs to offer updated information and guidance on record-keeping.

^{KEYWORDS:  DENTAL RECORDS, ELECTRONIC HEALTH RECORDS, MEDICAL RECORDS, DOCUMENTATION}