Course Overview:
This course provides a comprehensive understanding of the principles and best practices of clinical record-keeping. It reflects current data protection requirements and other relevant regulations. Learners will explore the importance of accurate, secure, and well-maintained documentation, and how this supports the dental team in delivering high standards of patient care, continuity, and professional accountability.
Course Aims:
- To emphasise the critical role of record-keeping in patient safety and professional standards.
- To outline the legal, ethical, and regulatory requirements for dental documentation.
- To prepare dental nurses to support clinicians in the accurate and secure maintenance of patient records.
Learning Objectives:
By the end of the course, learners will be able to:
- Identify the essential components of accurate and comprehensive dental records.
- Understand and apply the relevant GDC standards on record-keeping.
- Recognise the legal and professional requirements for data security and retention.
- Describe documentation practices for different appointment types.
- Explain the process and importance of recording informed consent.
- Demonstrate how to amend clinical records in accordance with professional guidelines.
Learning Outcomes:
Upon completion of this course, dental nurses will be able to:
- Maintain legible, accurate, and up-to-date clinical records in line with GDC Principle 4.
- Document valid consent for treatments and support patient understanding.
- Ensure confidentiality and security of records under UK GDPR and CQC regulations.
- Accurately document examinations, diagnoses, and treatments across a range of patient visits.
- Comply with retention schedules and the legal framework governing dental records.
- Appropriately use templates and make transparent corrections to documentation.
GDC Development Outcomes:
A, B, D
Review Date:
January 2027
