
Contents
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Record keeping Record keeping
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What should be recorded? What should be recorded?
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How long should records be retained? How long should records be retained?
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Retrieving records Retrieving records
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National Health Service (NHS) charting in the UK National Health Service (NHS) charting in the UK
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Orientation of the chart Orientation of the chart
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Numbering system Numbering system
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Examination procedure Examination procedure
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Using the chart Using the chart
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International Dental Federation (FDI) charting International Dental Federation (FDI) charting
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Permanent dentition Permanent dentition
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Deciduous dentition Deciduous dentition
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Numbering system Numbering system
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Basic periodontal examination (BPE) charting Basic periodontal examination (BPE) charting
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Examination procedure Examination procedure
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BPE scores BPE scores
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Full periodontal assessment Full periodontal assessment
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Examination procedure Examination procedure
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Accepted notations Accepted notations
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Using the chart Using the chart
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Study models Study models
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Making study models Making study models
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Recording progress by use of study models Recording progress by use of study models
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Patient charges and exemptions Patient charges and exemptions
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NHS charges in the UK NHS charges in the UK
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Costs Costs
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Private charges Private charges
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Exemptions Exemptions
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10 Assessment of oral health needs and treatment
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Published:May 2012
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Extract
Record keeping
► The importance of good, accurate record keeping cannot be emphasized enough. In the event of a patient making a complaint or an allegation against a member of the dental team the clinical records may be vital.
What should be recorded?
Records should contain facts and state the treatment that has taken place. Patients refusing treatment and failed or cancelled appointments should also be recorded in the notes.
Detrimental comments should be avoided.
How long should records be retained?
...
Retrieving records
Should a patient make a complaint, contact your appropriate defence organization. Keep all original documentation in a safe place—never send original documentation, always make copies. Advice should be sought on litigation matters as soon as possible.
National Health Service (NHS) charting in the UK
A method of dental charting has been developed that can easily be recognized and understood by all dental professionals. The system is a quick and easy way to record the dentition of an individual:
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