About this course
This free course is tailored for dentists, dental care professionals, receptionists, and practice managers. It focuses on enhancing the understanding and application of effective record-keeping practices within dental settings.
This course covers the legal and regulatory requirements of dental record-keeping and develops skills in creating accurate, complete, and contemporaneous dental records.
The course is structured to provide a deep understanding of the importance of records as legal documents in dental practice, ensuring compliance with the guidelines set by GDC, NHS, and CQC. It also emphasises the application of the SOAP format for clear and logical clinical note-taking and the effective management of computerised records.
This course is relevant to dentists, dental care professionals, receptionists, and practice managers.
CPD Time: 2 hours (2 CPD Credits)
Customer feedback on this course
- Highly informative, clarified all aspects of dental record-keeping.
- The course perfectly outlines the legal requirements and best practices.
- Excellent insights into the SOAP format and computerised records.
- Essential for anyone involved in dental practice management.
- Made record-keeping more understandable and less daunting.
Assessment: 12 MCQs. Pass mark 75%. more…
On passing the assessment you will immediately receive a GDC-recognised Enhanced CPD Certificate.
Aim:
To enhance the understanding and application of effective record-keeping practices in dental settings, focusing on the roles of both dentists and dental care professionals (DCPs).
Course objective:
• To understand the legal and regulatory requirements of dental record-keeping.
• To develop skills in creating accurate, complete, and contemporaneous dental records.
Anticipated learning outcomes:
The learner will:
• Recognise the importance of records as legal documents and their role in dental practice.
• Be able to identify and comply with the record-keeping requirements set by the GDC, NHS, and CQC.
• Understand the necessity of including all relevant patient details, clinical data, and treatment plans in records.
• Apply the SOAP format for clear and logical clinical note-taking.
• Manage computerised records effectively, ensuring security, accuracy, and compliance with GDPR.
GDC Development Outcomes:
A, D
Learning content:
Effective Dental Record-Keeping | UK Regulations | Record Contents | Standard Formats | Computerised Records | Altering Records | Radiographs | Patient Access | Long-term Retention | Treatment Plans | Course Completion
View full course description
Compliance in Record Keeping
Course Description
Effective Dental Record-Keeping
This section highlights the importance of maintaining accurate, complete, and timely dental records. Records serve not only as patient care tools but also as legal documents that can protect the dental practice in case of audits or disputes.
UK Regulations
Look at the UK-specific regulations governing dental record-keeping, as set by the GDC, NHS, and CQC. This section emphasises the need for compliance with legal requirements to ensure patient safety and avoid penalties.
Record Contents
A detailed guide on what information must be included in dental records, such as patient history, clinical findings, treatment plans, and follow-up care. Thorough record-keeping ensures continuity of care and legal compliance.
Standard Formats
The course introduces the SOAP format (Subjective, Objective, Assessment, Plan) as an effective way to structure clinical notes, ensuring clarity and consistency in patient records.
Computerised Records
With the digitalisation of dental records, this section covers best practices for managing computerised records, ensuring data accuracy, security, and compliance with GDPR regulations.
Altering Records
Learn the proper methods for modifying dental records, including the need for transparency, dating changes, and preserving original entries to maintain the integrity of the record.
Radiographs
This section covers the documentation of dental radiographs, including the justification for each radiograph, the optimisation techniques used, and the clinical evaluation of the images to ensure compliance with IRMER regulations.
Patient Access
Patients have a legal right to access their dental records. This section outlines the steps for providing timely access while adhering to data protection laws.
Long-term Retention
Understand the guidelines for retaining dental records, including the legal requirements for complex cases and the NHS retention schedule, which dictates how long records should be kept.
Treatment Plans
A comprehensive treatment plan should include diagnosis, proposed treatments, alternatives, risks, timeframes, and cost estimates. This section emphasises the importance of clear and detailed documentation to ensure patient understanding and legal protection.
Course Completion
Participants will complete a feedback survey, take a multiple-choice exam, and receive a GDC-compliant CPD certificate. The course emphasises the importance of accurate, compliant, and thorough dental record-keeping for improved patient care and legal security.
You can copy and adapt this example PDP entry for your own needs and circumstances. The format complies with GDC guidance on PDP structure.
| PDP Learning or Maintenance need |
| Enhancing knowledge and skills in effective dental record-keeping. |
| How does this relate to my field of practice? |
| Very important for maintaining high standards of patient care and legal compliance. |
| Which development outcome(s) does it link to? |
| A, D |
| What benefit will this have to my work? |
| Improved accuracy and compliance in record-keeping, leading to better patient management and reduced legal risks. |
| How will I meet this learning or maintenance need? |
| Enrol in the "Record Keeping" course for comprehensive learning. |
| When will I complete this by? |
Note: After copying and adapting the suggested PDP entry, remember to reflect, plan, act, and evaluate for every CPD activity you undertake.