Clinical examination and record-keeping

Clinical Examination and Record-Keeping: Good Practice Guidelines is a complete reference guide to record-keeping and examination.

Covering dental records, history-taking, full examination, recall visits, consent, confidentiality, data protection, referrals, electronic records, special situations and more, the third edition has been fully updated and expanded to reflect technological and regulatory developments. It also includes scenarios to put the guidance into context, as well as a series of extensive appendices, diagrams, charting notes and template forms which dental professionals may adopt for use in their practice.

Its recommendations – which the Care Quality Commission expects dental practices in England to comply with when recording medical history, assessing needs, and planning and recording care – are categorised for simplicity into ‘basic’, ‘aspirational’ and ‘conditional’.

“This publication provides good practice guidelines in clinical examination and record keeping for primary dental care practitioners. It is relevant, clear, well structured, accessible and an excellent reference tool”

British Dental Journal

Related articles

CGDent members can view full articles via the links below by first visiting the PDJ Member Access page and clicking ‘Access the PDJ Archive’.

• Dento-Legal Implications in Primary Care Oral Surgery by Clare Lawrence (October 2020)

• Gaining and Recording Consent: A Practical Guide for the Dental Team by Alexander C L Holden (October 2020)

• ‘If it Ain’t in the Notes…’ Dental Record-Keeping in Adversity by Stephen Henderson (June 2019)

• The Admin Effect: Managing the Orthodontic Patient Journey to Ensure Patient Satisfaction and Quality of Care by Isobel Fennell, Suzi Rammell, Jen Blakeman (December 2016)

• Clinical Recordkeeping for Monitoring Treatment Outcomes in Implant Dentistry: A Case Study by Ashok Sethi, Thomas Kaus, Naresh Sharma (June 2013)

Non-members who wish to read one of these papers, or other Primary Dental Journal articles, have the option to join the College or subscribe to the PDJ.