Copyright FGDP(UK) 2016. No part of this publication may be reproduced without permission.
CHAPTER 8 ELECTRONIC RECORDS
8.2 Contents of electronic records
8.3 History taking
8.4 Full examination
8.5 Hard tissue - tooth examination
8.6 Periodontal considerations
8.8 Treatment plan
8.9 Recall examination
8.10 Emergency appointments
8.11 Referral to other clinicians
8.13 Retention of records
8.14 Encryption of records for transfer
Electronic records are now widely used in medical and dental practices, and there is the increasing possibility to move towards a ‘paperless’ practice. While generally they can do the same as paper records, there is the capability of pulling together an integrated patient record and practice management system with a wide range of facilities, all in one place. This can include patients’ clinical records, diagnostic imaging, patient reminders, treatment plans, along with management systems, such as appointments, accounts, correspondence, and laboratory prescriptions.
Many software programs available allow remote access to files, as well as structured templates to suit the individual clinician. Electronic records offer many advantages, including legible notes, but also come with some disadvantages.
The principles of the entries in electronic records are identical to those referred to earlier in this book.
From the list in chapter 2, the following variations apply to electronic records:
- Ensure all entries are dated, timed and the clinician and assistant are identified.
- Any errors should be identified by a later correcting entry, which refers to the error.
- When a printout is required, ensure pages are numbered and identifiable by name and identifier such as the address or date of birth of the patient.
When printing out electronic records, all data that can be reasonably printed out should be done. Printing of selective data can cause problems in assessing the care undertaken. An example is the printing out of ‘void entries’ where amendments had to be made to records. The software must allow the printing in full of all items ofthe dental record as detailed in chapter 2.
The clinician should be familiar with the system used, and be able to locate and understand the information that has been entered.