Best practice in record keeping
A routinely high standard of record keeping is essential for a dental team who take safeguarding children seriously. Records must include accurate basic personal information about every child and comprehensive clinical records of their dental care.
Basic personal information
When a child attends any healthcare service for the first time, basic personal information must be recorded. Accurate records of these simple details contribute to safeguarding children. The information required is defined in government guidance28 and must be recorded for every child and checked for changes at every visit:
date of birth
name(s) of person(s) with parental responsibility
primary carer(s), if different.
‘Front-line staff in each of the agencies which regularly come into contact with families with children must ensure that in each new contact, basic information about the child is recorded’
Recommendation 12, Victoria Climbié Inquiry 4
When treating children, in addition to details of examination, diagnosis and treatment provided, it is good practice to record:
who accompanied the child and, if not the parent, their relationship to the child
observations of behaviour, not only physical signs
a summary of any discussions with the child and parent.
These recommendations apply at any time, even when there are no concerns about the child. When there are child protection concerns, the following additional points are particularly pertinent:
record observations and reasons given for seemingly trivial injuries which may, over a period of time, show a repeating pattern of injury
make diagrams in addition to written descriptions (drawings, either freehand or on a mouth, face or body map proforma (download
face map proforma) or clinical photographs with consent) clearly labelled with the child’s name and date
record observations in a way that will be understandable to colleagues so that, even if no single team member gets to know the child well, a written record builds up over time. This overcomes the problem that abusers sometimes avoid detection by taking a child to different practitioners on different occasions so that no-one picks up on ‘the big picture’
clearly state the difference between the facts and your opinion
keep administrative notes such as attendance, non-attendance and cancelled appointments in addition to the clinical notes
keep a list of questions to ask yourself when assessing a child, in paper based (download
question prompts) or electronic format (view example below).
Custom screen in electronic patient records (reproduced with permission of Software of Excellence)
The clinical records should be:
accessible only to health professionals who 'need to know'
readily accessible to health professionals who need to know, so should be stored in one place
stored securely: paper-based records should be stored in locked filing cabinets in rooms accessible only to staff, and never left unattended when in use; electronic records should be password protected.Further guidance on clinical record keeping is available from other sources.36
‘Over the years he had seen several of us at the practice and had been referred for GA extractions but had missed a number of appointments at the hospital. It was only because of my colleagues’ detailed record keeping in the past, including what they had explained to his mum, that I could see how his needs were being neglected and so had the confidence to act’|
A dentist reflecting on the care of an 11-year-old child who returned for a second time with a swollen face due to a severe dental infection
‘In court there was a discussion about who was given the dental appointment card - it was only the fact that the receptionist had written down that she gave it to the social worker, and not the parent that helped the family show in court that on this occasion they had not wilfully missed the dental appointment – of course this was only a tiny part in a much bigger picture, but we were thanked for the accuracy of our record keeping’
A practice manager after being asked to submit evidence in a child protection case