What belongs in a dental patient record

A patient record has two jobs. Day to day, it tells you what you did last time. Rarely — but when it matters most — it is the evidence that what you did was reasonable and that the patient agreed to it.

Records written only for the first job fail badly at the second.

The permanent part

Recorded once, updated when it changes:

• Full name, date of birth, phone number
• Medical history: current conditions, medications, anticoagulants, pregnancy, diabetes, cardiac history
• Allergies, especially to anaesthetics, latex and antibiotics — this should be impossible to miss when the record opens
• Smoking status
• Emergency contact
• Referring dentist or physician, if any

Medical history is not a one-time form. Ask again at least annually — patients start medications and do not think to mention it.

After every visit

Written the same day, not from memory a week later:

1. Date and who performed the treatment. In a multi-dentist clinic this is the field most often missing and most often needed.
2. Chief complaint in the patient's own words. "Pain when biting on the upper left" is worth more than "pain."
3. Findings, including the teeth examined, not only the ones treated.
4. What you did, by tooth number, with materials used and anaesthetic type and quantity.
5. What you advised, including alternatives discussed and what the patient declined.
6. Next step and the interval.

Point 5 is the one clinics skip and the one that matters most. A note saying a patient was offered a crown and chose a filling protects both of you. Its absence leaves only two competing memories.

Radiographs and images

Every image needs a date and a reason. An X-ray in the file with no indication of why it was taken is a problem in any review.

Keep the originals, not just a report. Store them against the patient record rather than in a folder on the imaging machine — that folder always becomes unsearchable within two years.

Consent

For anything invasive, irreversible or expensive, record that consent was given, when, and what the patient was told: the procedure, the alternatives, the risks, the cost.

Verbal consent counts, but only if it is documented. A line in the record written on the day is worth far more than a signed form nobody read.

How long to keep records

Rules vary by country, so check your local requirement. As a working default, clinics keep adult records at least ten years from the last visit, and for children until some years past the age of majority.

Do not delete anything before you have confirmed the local rule. The cost of storing records is trivial; the cost of not having them is not.

Habits that cause trouble later

• Abbreviations only you understand. Records get read by colleagues, by a locum, and occasionally by someone in a dispute.
• Writing up several days at once. Detail is gone by then, and the record shows it.
• Editing old entries. Add a dated addendum instead. A record that appears rewritten is worse than one that is simply incomplete.
• Recording only treatment. Cancellations, refusals, no-shows and phone advice all belong in the record too.

A useful test

Read a record from six months ago and ask: could another dentist take over this patient tomorrow using only this?

If not, the gap is what to fix first.

In DOQ, clinical notes attach to the visit and the tooth, allergies surface at the top of the record, and nothing is deleted — edits are versioned.