Guidelines for Dental

Record Maintenance
©
in India

Diary. No 10848/2020-CO/L

Authors:

Selwin Samuel, M B Aswath Narayanan, Dhwani Patel

1
 Index

CONTENTS PAGE NO

Guidelines for Recording A Case History Form

3

Guidelines for Maintaining an Informed Consent Form

4

Consent From (Model)

5

Guidelines for Recording Photographs in A Case History Form

6

Guidelines for Maintaining Radiographic Records

7

Guidelines for Maintaining Dental Models

8

Guidelines for Recording Drug/Laboratory Prescriptions

9

Guidelines for Handling Referral Correspondence

10

Guidelines for Maintaining Ancillary Records

11

Guidelines for Ownership and Retention of Records

13

References 14

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 GUIDELINES FOR RECORDING A CASE HISTORY FORM*

The registered dentist must ensure that service users are protected against the risks of unsafe
or inappropriate care and treatment arising from a lack of proper information about them by
means of the maintenance of an accurate record in respect of each service user which shall
include appropriate information and documents in relation to the care and treatment provided
to each service user. The following are the protocols to be followed while drafting and
maintaining a service user’s dental record.

1. Use a consistent style for entries — the appearance of the record is enhanced by using
the same color and type of pen, use the same abbreviations and tooth notations, and so
on.

2. Date and explain any corrections — it may be a fatal error in a malpractice case if
records appear doctored in any way. These unexplained corrections can undermine the
credibility of the entire record and of the treating dentist.

3. Use single-line cross out — this preserves the integrity of the record and shows that
you have nothing to hide.

4. Do not use correction fluids — not only is this messy, but it is conspicuous and may
indicate that there has been an attempt to hide information.

5. Use ink — pencil can fade and opens up the question of whether or not the records
have been altered.

6. Write legibly — an illegible record may be as bad as no record at all. Difficult to read
entries can lead to guesswork by others and this may not be favorable to you.

7. Document fully — there is no need to be sparse with notes, a detailed explanation is

always better than one lacking information.

8. Only use accepted abbreviations for treatments — this is helpful both in malpractice
situation and also when transferring records to a different dentist for referral, prior
approval or a change in dentist.

9. Collate documents — details from third parties should be separate from those items
that pertain directly to patient care.

10. Maintain appropriately — the maintenance of a file for every patient is recommended.
All files should be easily accessible. A dentist must keep records safely and securely.
Keeping them securely also requires that they are kept confidential.

*Adopted from the practices of National Health Service and UK dentistry1.

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 GUIDELINES FOR MAINTAINING AN INFORMED CONSENT FORM2,3*

1. Every clinician must commence any procedure in his own clinic (including routine
examinations) after obtaining an informed consent in a written form. The clinician
must not perform any treatment if he does not have a mutually agreed informed
consent for screening or the treatment.

2. The patient should be explained the procedure and its significance in a language the
patient can properly understand. If need arises, the clinic should provide consent
forms to the patient in vernacular languages.

3. A written consent should contain agreement from the patient supported by a signature,
implying that the patient was described and clearly explained the nature and the
possible outcomes of the treatment, both positive and negative and was also ensured
confidentiality regarding the same, except during the times requiring consulting the
necessary information with a competent dental expert for proper treatment.

4. If any patient does not agree for a treatment even though the treatment would benefit
the patient when performed, the dentist ought to make a written statement with the
patient’s signature stating that the patient refused to undergo the treatment, despite
advice.

5. A consent form should have the proposed date of the procedure, the approximate
duration of procedure and the name of the dentist (or consultant) who will perform the
treatment.

6. Any informed consent should preferably be signed before the treatment. This will
help the both the patient and the doctor to be well prepared for the procedure. If the
patients change their mind at any point before the procedure, they may withdraw their
previous consent by expressing valid reasons.

7. Every procedure requiring a consent should be obtained by individual consent forms.

Two or more procedures cannot be consented in a single consent form. For example,
extraction of impacted #38 and #48 would mandate separate consent forms.

8. The consent form(s) should be safely filed as patients’ record, along with the other
dental records in chronological order.

9. The consent form should be treated as an essential dental record. Hence, there should
be no overwriting or usage of correction pens and pencils in the consent form.

10. Any individual below 18 years and those who do not possess the mental competence
to consent do not reserve the liberty to consent. A guardian should accompany the
patient and provide consent on behalf of the patient. The guardian who provided the
consent should accompany the individual on the prescribed day of treatment whose
absence will refrain the dentist from performing the treatment.

*Instead of signatures, thumb impressions may be given, depending on the individual,

wherever mentioned.

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 CONSENT FROM (Model)

Prepared in accordance to the record maintenance protocols proposed by American

Dental Association4

Name of the clinic (Clinic’s letter head is preferable)

Name of the patient:

Patient’s ID No:

Proposed Treatment:

Date and time of treatment:

Name of the treating dentist:

I hereby declare that I consent/refuse to undergo the above-mentioned treatment after the
dentist provided me information on my dental health problems. I was clearly informed the
nature of the proposed treatment, the potential benefits and risks associated with the
treatment, any alternatives to the treatment proposed, and the potential risks of not
undergoing the treatment and benefits of alternative treatments.

Signature of the patient

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GUIDELINES FOR RECORDING PHOTOGRAPHS IN A CASE HISTORY FORM

1. A recent passport size photograph of the patient should be affixed to the top right
corner of the first page of the case record. As any patient is not expected to have a
passport size photograph in the first visit, the clinic employees should insist the
patient to provide the clinic, their photographs in the subsequent visit. Alternatively,
the photograph of the patient can be made at the clinic and the same can be affixed.

2. The following photographs should be made and recorded as essential records

irrespective of the patients’ treatment needs5.
 Full face photograph with eyes open (without spectacles) and mouth closed
frontal* and lateral profiles.
 Close-up photograph of the anterior teeth in occlusion.
 Close-up photograph of the anterior teeth at wide-open position.
 Right and left lateral views of the teeth in occlusion or their proper bite.
 Views of the occlusal surfaces of the teeth of both jaws (also palatal rugae in case
of maxillary arch).
 Photograph of the lips at rest position.
 Close-up photography of any additional features that may be important (such as a
lesion, developmental anomaly, injury, any significant scars, etc.).
3. All photographs must be preferably stored in either TIFF or RAW format6 in
electronic devices such as laptops, PCs and tablets, restricting the accessibility to only
the employees of the clinic (on a need basis). All clinical photographs of a single
patient should be assigned a separate folder and named with patient details for future
reference purposes.

4. If the clinic does not have any electronic devices to store the photographs, then the
patients’ photographs should be aptly printed and stored in the patients’ dental record
files.

5. The photographs should not be edited copied or distributed to any third party without
prior permission from the patient or guardian (if the patient is below 18 years,
permission should be obtained from the parent/guardian only).

* The length of the lips should be measured with the help of a divider such that it stands as a
reference for making measurements in the full face photographs if any need arises in the future
for measuring the face as a whole or in parts.

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 GUIDELINES FOR MAINTAINING RADIOGRAPHIC RECORDS

1. All radiographs whether extra-oral or intra-oral are to be stored in the file and should
not be given to patients as a matter of routine. If the patients need the radiographs for
second opinion or any other personal reasons, they may take away the radiographs
after submitting a written request to the concerned dentist.

2. A radiograph is not considered valid if it does not have the date and name of the
patient on it. This may be not applicable for IOPA radiographs and occlusal
radiographs that are made in the dental clinic.

3. Any patient should be advised for an OPG, regardless of the chief complaint of the
patient. This will stand as a valid evidence to show the presence or absence of any
abnormality. The OPG can also display any asymptomatic lesions that are present in
relation to teeth, bones and soft tissues7. Today, an OPG is equivalent to the full
mouth radiographs that were mandated in earlier years and also an adjuvant to
models. So, an OPG is a must.

4. In addition to the OPG, additional radiographic aids shall be advised whenever

situation demands. Failing to make a diagnostic radiograph in vital conditions should
be avoided.

5. A radiograph should match the optimal diagnostic quality to aid in detecting even the
incipient lesions. A radiograph that is not of good quality has no diagnostic value
besides failing to stand against dentolegal affairs8.

6. All radiographs should be stored in the patients’ record as long as the records are
retained in the dental clinic. No radiographs should be discarded for any reason.

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 GUIDELINES FOR MAINTAINING DENTAL MODELS

1. All diagnostic dental casts should be stored in the clinic as essential dental records till
the other records of the patients are retained. The dental casts include those made for
orthodontic, prosthodontic, as well as other surgical and restorative purposes.

2. Dental practitioners may also store dental models so that they recall their patients to
monitor changes in occlusion and other structures, besides serving its role as a
potential forensic tool8.

3. Orthodontic diagnostic and treatment casts shall be retained for seven years.
Additionally, diagnostic casts relating to prosthetic replacements such as crowns,
bridges, and implants may also be required to be retained for seven years.

4. If storage of the casts presents a problem, the patient can be asked to store them and
be advised of their importance for future possible changes10.

5. If the casts are not in a storable quality or when there is a limited space for storage of
diagnostic casts in the clinic, the casts can be photographed and then discarded4.

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GUIDELINES FOR RECORDING DRUG/LABORATORY PRESCRIPTIONS

1. A medical prescription should be written only on sheets with clinic’s letterhead or on

ones that have the clinic’s stamp/seal along with the name of the dentist who
prescribed the drugs.

2. Drug prescriptions should be written neatly, clearly and legibly. There should be no
overwriting or erasing in the drug prescriptions.

3. A drug prescription should definitely contain the patient’s name, age, clinic’s ID
number, followed by the name of the drug, its dosage, frequency and duration with
details such as whether the drug should be taken pre-prandial or post-prandial9.

4. Laboratory prescriptions usually contain the laboratory’s identity and are available in
pre-designed templates. The laboratory prescriptions should be properly and
completely filled and sent to the laboratory without overwriting or erasing, and with
patients’ details just as expected in drug prescriptions.

5. It is however recommended for both drug prescriptions and laboratory prescriptions to

make carbon copies. This initiative can help the patient, lab technician and the
dentists to have records on each side, for future reference purposes and also saves
time, eliminating the need to rewrite, which mitigates possibilities of errors during
reproduction of prescriptions.

6. The prescriptions (carbon copies) should be filed with the patients’ other records and
retained as long as the other dental records are stored in the clinic1.

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 GUIDELINES FOR HANDLING REFERRAL CORRESPONDENCE4,11,12

1. A dentist usually refers a patient to another dentist or to a medical specialist when the
dentist needs additional information about the patient’s health to plan a treatment or
when the dentist thinks that the expert whom the patient is referred to can handle the
patient’s problems better. However, patients should be well informed about their
referrals before the correspondences are made.

2. It is better if a dental clinic prepares its unique referral correspondence templates so

that the referral process becomes easier when referrals are done on a regular basis.

3. A referral correspondence should contain the following information

• Name, age, sex, clinic ID and contact information of the patient being referred
• Reason for referral
• The presenting complaint of the patient
• A brief idea of the patient’s medical history, drug history, dental history, allergy,
family history, etc. (if there is no relevant history, that has to be mentioned)
• Diagnostic impression of the referring dentist
• Future treatment plans of the referring dentist
• Signature of the referring dentist
If any of this information is missing, the referred dentist should request the referring
dentist to resend the referral correspondence with all information in it.

4. The referral correspondence can be sent either electronically by scanning the letter or
by post or even through the referred patient, who can handover the letter to the
specialist during his/her visit.

5. The referred dentist is expected to send an acknowledge letter once the correspondence
has been received (by whichever means). This will help the referring dentist to track the
information about his/her patient’s dental health.

6. The referred dentist is at liberty to record a complete history after a comprehensive

dental examination or he/she may make a short dental record relevant to the treatment
which the patient is referred for. The referred dentist may anytime request the referring
dentist for a copy of the patient’s dental record.

7. During treatment, the referred dentist may make or advice radiographs, photographs,
medical investigations, etc., whenever there is a need, and store them separately from
his/her own patient records. These records may be stored in a file, electronically or in
papers and a copy may be sent to the referring dentist for his/her reference.

8. During the course of the treatment, the referred dentist should frequently update the
progress of the treatment through correspondences, so that there is a mutual exchange
of information regarding the health of the patient.

9. Once the treatment has been culminated, the referred dentist should inform both the
patient and the referring dentist (through correspondence). The patient shall resume
treatment under the referred dentist or the referring dentist depending on the desire of
the patient.
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 GUIDELINES FOR MAINTAINING ANCILLARY RECORDS

A. Maintaining Investigation Reports1,9

1. If the dentist needs to know the general health profile of a patient, the dentist may
advise the patient for some pertinent investigations. Alternatively, already available
investigation reports, revealing patient’s latest health status can be obtained from the
patient.

2. The dentist may either keep the original investigation report of the patient or request
the patient to provide a copy of the investigation reports to the clinic, depending on
the patient’s need, along with patient’s dental records.

3. Like other records, investigation reports should also be kept confidential and the
information must not be shared with anyone without the permission of the patient.

B. Maintaining Digital Records9,13

1. Digital records such as RVGs, digital impressions, CAD-CAMs, information

management systems, etc. may be used in addition to other necessary dental records
and should safely be recorded
2. These digital records must provide prompt access to information, be capable of
generating appropriate clinical reports, be regularly backed up and periodically
updated.

3. It must not be possible for anyone to tweak entries, which means, audit trail and
security procedures such as access being available only by password should be
sincerely practiced due to preservation of confidentiality14.

4. There must be a standard procedure for entering digital records in a dental office. The
entries should be manually done either by the dentist or the clinic staff with proper
details of the patient labelling the records appropriately, so that wrong entries can be
avoided.

C. Maintaining Business Records9,15

1. It is prudent to include in the patient record a note about the agreements made with
the patient and/or guardian concerning the settlement of bills including those incurred
for screening purposes either in a paper form or digital form.

2. The bill shall be customized as per the clinic’s tariff pattern and should not be
included in the patient dental record file. It is recommended that the clinic prints bill
books that has the clinic’s identity. However, care should be exercised by the dentist
while handling bill books as they may be misused.

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3. The financial record for each patient must include the date and amount of all fees
charged, the date and amount of all payments made, signatures of the clinic in-charge
and the patient/guardian and whether the bills were settled by the patient or third
parties.

4. Laboratory based bills related to patient’s treatment shall be preserved in either the
patient’s billing record (not clinical record) or in a separate file till the patient’s dental
records are retained in the clinic.

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 GUIDELINES FOR OWNERSHIP AND RETENTION OF RECORDS

Adopted from the practices of the members of American Dental Association and
Australian Dental Association4,16

1. Dental records should be retained:

i. in the case of an adult – for at least seven years from the latest date on which a
dental service was provided to the patient by the dentist.
ii. in case the individual was under the age of 18 years – at least until the
individual has reached the age of 25 years.
iii. in case the individual is dead – at least for a period of two years from the latest
date of a dental treatment.

2. If you delete or dispose of health information, you must keep a record of the name of
the individual to whom the health information related, the period covered by the
record, and the date on which is was deleted or disposed of.
3. A dentist who transfers health information to another organization and does not
continue to hold a record of that information must keep a record of the name and
address of the organization to which it was transferred.

4. Unless needed by law or transfer of dental records to another treating dentist with
the permission of the patients, copies and not originals of records should be released.

5. If original dental records are released for forensic or referral purposes, dental
practitioners should obtain an acknowledgment receipt and also retain copies for
their own records.

6. The patient reserves all rights to access their dental records at any time with prior
permission from the treating dentist. Upon request, the dentist may provide a copy of
the dental records to the patient which has to be received from the patient in
writing9.

7. The dentist is responsible for the safety of dental records. The dentist must protect
the dental records from being stolen or misplaced by storing them in a secure place.
Restriction of access to the records can be made by securely locking the records in
shelves.

8. The dental records can be scanned and loaded into the electronic devices such as
computers, laptops, tablets, etc. for backup purposes. This will help the dentist
during loss or damage to dental record files. So, it is considered prudent to make
electronic backups9.

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REFERENCES:

1. Charangowda BK. Dental records: An overview. Journal of forensic dental sciences.

2010 Jan;2(1):5.
2. Indian council for Medical Research; Ethical Guidelines. Available from:
http://www.icmr.nic.in/ethical_guidelines.pdf. [Last accessed on 2018 Jan 5].
3. Reddy KA. The essentials of forensic medicine and toxicology. K. Suguna Devi;
2007..
4. Council on Dental Practice and the Division of Legal Affairs. Dental records -
American Dental Association; c2007. Available from:
http://laneykay.com/dentalpractice_dental_records.pdf. [Last accessed on 2018 Apr
9].
5. Herschaft EE, editor. Manual of forensic odontology. CRC Press; 2011 Sep 26..
6. Robinson EM. Crime scene photography. Academic Press; 2016 Jun 12.
7. SC W, Pharoah MJ. Oral radiology: principles and interpretation. St Louis, Mo:
Mosby Elsevier. 2009.
8. Samuel SG, Pandey A, Dahiya MS. A report on the current status of radiology in
forensic odontology in the Indian scenario. International Journal of Forensic
Odontology. 2017 Jan 1;2(1):34.
9. Devadiga A. What's the deal with dental records for practicing dentists? Importance in
general and forensic dentistry. Journal of forensic dental sciences. 2014 Jan;6(1):9.
10. Grippo JO, Kristensen GJ. The importance of making and retaining diagnostic casts.
Dent Econ. 2015;2:2-4.
11. Hays R. Teaching and learning in primary care. CRC Press; 2016 Jul 6.
12. Gaylor LJ. The Administrative Dental Assistant-E-Book. Elsevier Health Sciences;
2016 Jan 7.
13. Dental Recordkeeping Guidelines – College of Dental Surgeons of British Columbia.
Available from: https://www.cdsbc.org/CDSBCPublicLibrary/Dental-Recordkeeping-
Guidelines.pdf. [Last accessed on 2018 Apr 11].
14. Chowdhry A, Sircar K, Popli DB, Tandon A. Image manipulation: Fraudulence in
digital dental records: Study and review. Journal of forensic dental sciences. 2014
Jan;6(1):31.
15. Royal College of Dental Surgeons of Ontario. Dental Record Keeping - Guidelines;
2008. Available from: http://www.rcdso.org/save.aspx?id=509b50b6-aa32-450a-
9ae9-5f5c8cb53749. [Last accessed on 2018 Apr 11].
16. Dental Records - The Australian Dental Association. Available from:
https://www.ada.org.au/Dental-Professionals/Policies/Third-Parties/5-17-Dental-
Records/ADAPolicies_5-17_DentalRecords_V1. [Last accessed on 2018 Apr 11]

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