Records management is the process by which our practice manages all the aspects of its records, whether internally or externally generated and in any format or media type, from their creation to their eventual disposal.

The practice’s records are its memory, providing evidence of actions and decisions and supporting its daily functions and operations. The records management policy protects the interests of the practice and the rights of patients, staff and members of the public. They support consistency, continuity, efficiency and productivity and help deliver our services consistently and equitably.

The NHS has published a code of practice as a guide to the required standards of practice in the management of records for those who work within organisations in England. Although this is written by the NHS, private practices are also advised to follow this guidance. It is based on current legal requirements and professional best practice. The following records management procedures are based on the code of practice and have been developed for use in our dental practice.

Scope

These procedures relate to health records held in any format by our practice. A health record is anything which contains information (in any media) which has been created or gathered to provide commissioned services, including:

All administrative records, including personnel, estates, financial and accounting records, and notes associated with complaints.
All patient records, including patient record cards, x-ray and imaging reports, registers, appointment books, orthodontic and other study models, referral letters, treatment estimates and any other records that fall into this category.
Electronic records, including computer databases, output, disks, etc.
Emails

The practice has adopted a records management policy as it will gain several organisational benefits. These include:

Better use of physical space.
Better use of practice computer space.
Better use of staff time.
Improved control of information.
Compliance with legislation and standards; and
Reduced costs in management and storage and ultimately in destroying patient records.

The key components of records management are:

Record creation
Record keeping
Record maintenance
Access and Disclosure
Closure and transfer
Appraisal
Archiving
Disposal

Aims of our Records Management System

Our records management system aims to ensure that:

Records are available when needed – from which the practice can form a reconstruction of activities or events that have taken place,
Records can be accessed – records and the information within them can be located and displayed in a way consistent with their initial use, and the current version is identified where multiple versions exist,
Records can be interpreted – the context of the record can be interpreted: who created or added to the record and when, during which process, and how the record is related to other records;
Records can be trusted – the record reliably represents the information that was used in or created by the business process, and its integrity and authenticity can be demonstrated,
Records can be maintained through time – the qualities of availability, accessibility, interpretation and trustworthiness can be maintained for as long as the record is needed, perhaps permanently, despite changes in format,
Records are secure – from unauthorised or accidental alteration or erasure, that access and disclosure are adequately controlled, and audit trails will track all use and changes.

To ensure that records are held in a robust format which remains readable for as long as records are required;

Records are retained and disposed of appropriately – using consistent and documented retention and disposal procedures, which include provision for appraisal and the permanent preservation of records with archival value and
Practice staff are trained – so that all staff are made aware of their responsibilities for record-keeping and record management.

The guidelines that govern patient record-keeping

There are two primary sources of guidelines governing patient record keeping, namely the College of General Dentistry (CGDent) (formerly The Faculty of General Dental Practice (FGDP UK)) and the General Dental Council (GDC).

The College of General Dentistry (formerly FGDP)

CGDent (formerly FGDP) published Clinical Examination and Record-Keeping – Good Practice Guidelines in 2001 and updated these guidelines in 2009, then again in 2016.

The General Dental Council (GDC)

In 2013, the GDC published the first in its series of standards documents governing the practice and conduct of dentists registered in the UK. All registered dentists must abide by the GDC’s published guidance, and a failure to do so can bring a dentist’s registration into question.

‘Standards for Dental Team’ outlines the principles of dentistry practice and provides guidance on applying these 9 standards.

Standard 4.1 of the guidance states that a practice must “make and keep contemporaneous, complete and accurate patient records.”

Roles and Responsibilities

Jasmin Jones has overall responsibility for records management in the practice. They are responsible for the management of the organisation and for ensuring appropriate mechanisms are in place to support service delivery and continuity. Records management is key to this as it will ensure appropriate, accurate information is available as required.

The practice is responsible for ensuring that it meets its legal responsibilities and for adopting internal and external governance requirements.

The Caldicott Guardian

Jasmin Jones, the practice’s Caldicott guardian, is responsible for reflecting patients’ interests regarding the use of patient-identifiable information. They are responsible for ensuring patient-identifiable information is shared appropriately and securely.

Jasmin Jones is responsible for ensuring that this policy is implemented and that the records management system and processes are developed, coordinated and monitored.

Practice Team

As part of its operational responsibility, the practice team is responsible for the overall development and maintenance of health records management.

All clinical or administrative staff who create, receive and use records have records management responsibilities. All staff must ensure that they keep appropriate records of their work in the practice and manage those records in keeping with this policy and any guidance subsequently produced.

All practice staff will be informed of their responsibilities for record-keeping and record management through training and guidance.

Legal and Professional Obligations

The UK GDPR
The Data Protection Act 2018.
The Freedom of Information Act 2000.
The Common Law Duty of Confidentiality,
Any new legislation affecting records management as it arises

Clinical Audit and Peer Review

Clinicians need to participate in a form of audit and peer review relevant to their scope of practice. This must be carried out at a frequency pertinent to the degree of risk and the findings of earlier audits. Audits and reports might be expected when regulatory inspection/investigation occurs or as part of a complaint investigation.

An audit is a systematic method for evaluating anything you do to improve whatever you are auditing.

The profession and the public expect healthcare professionals to participate in peer review as an essential tool in maintaining and improving standards of clinical care.

Local circumstances and the clinical interests of individual clinicians will determine peer review processes. A formal peer review process might be convened in practice because of a regional clinical need. This might be a matter of clinician discussion. Irrespective of how informal these discussions might be, they should be recorded with a note of any outcomes and actions subsequently implemented.

Maintenance of records

The quality and condition of health records are vital to the service user and the organisation. Therefore, the organisation ensures that equipment used to store documents on all types of media (paper, memory stick, x-ray, etc.) provides storage that is clean, safe and secure from unauthorised access or environmental damage and which meets health & safety and fire regulations, but which also allows maximum accessibility of the information proportionate to the frequency of use.

Hard-copy records that are in constant or regular use or are likely to be needed quickly are stored in secure, lockable filing cabinets, which comply with current Health and Safety regulations. The practice ensures that the area containing health records is always locked when left unattended.

The practice stores semi-current physical records in an archive storage facility (which may be within the practice) that protects the records from environmental damage, such as excessive light, flooding, dampness and dust.

Use of records

Accurate recording and knowledge of the whereabouts of all records is crucial if the information they contain is to be located quickly and efficiently. One of the main reasons why records are misplaced or lost is because their next destination is not recorded anywhere.

The practice complies with the common law duty of confidence and ensures that staff members are provided with guidance on disclosures of service user information in its staff confidentiality policy.

Jasmin Jones will ensure that when records are transferred or taken offsite, e.g., to a group practice, it is in accordance with good information security practice to ensure records are protected from unauthorised access or loss.

The practice has put the following processes in place:

If paper records are being delivered to another location, they are enclosed in envelopes or opaque wallets and sealed for transfer;
Any paper records that may be damaged in transit are enclosed in suitable padding or containers;
Records contained on portable media (memory sticks, etc) are encrypted;
Larger quantities of records are boxed in suitable boxes or containers for their protection;
Each box or envelope is addressed clearly and marked confidential with the sender’s name and address on the reverse of the envelope and signed for on receipt;
The delivery service chosen for each transfer offers a level of security appropriate to the degree of importance, sensitivity or confidentiality of the records, and all relevant insurances are in place with the transferring agent.

Record Keeping

Records at the practice are kept safely and confidentially.

Comprehensive, accurate, legible, and contemporaneous patient records are vital to good patient care and risk management. While this is widely known, many clinicians continue to keep records that expose them medico-legally.

All entries should be dated, with the following minimum information always recorded:

Personal details
- Name
- Date of birth
- Address
- Contact telephone number and email address
- GP details
- NHS number (where applicable)
- Occupation
- The name and contact details of the person to be contacted in an emergency
- If a patient is purely private, the preferred payment method is, e.g., fee per item, payment plan, or insurance.
Medical history proforma every 12 months (or with each new course of treatment) with updates at every exam
What the patient is complaining of (c/o), including no complaints
Social history, including smoking and alcohol
Extra-oral examination/TMJ / Nodes (including all negative findings)
Soft tissue exams (S/T) (including all negative findings)
BPE – at every examination visit and periodontal pocket charts when appropriate, i.e., when BPE codes of 3 and 4
Chart of existing and required restorations, including ‘watches’
Caries and wear and tear
Radiographs that are taken at appropriate intervals according to patient risk status/clinical need, and written reports for all radiographs
Caries and periodontal disease risk assessments
Diagnosis (if appropriate)
Discussions of all treatment alternatives and options, with reasons behind any treatment decisions
Treatment plans and valid consent (including treatment declined)
Prescription to hygienist/referral to any specialist
Any correspondence from specialists
LA, any drugs prescribed, all treatment details and all materials used.
Warnings given of any potential adverse consequences of treatment.
Any complications arising during treatment.
All advice given.

Clinicians should audit their patient records to ensure they are following these good practice guidelines. A patient record audit proforma is available in the audit folder on the portal. When the CQC or any other regulator inspect practices, they will expect to see evidence that clinicians have audited their patient records frequently and regularly.

Medical history

The medical history proforma should be signed by the patient and then checked with the patient, either by the dentist or by an appropriately trained dental nurse, before the dentist signs it to confirm its accuracy.

The medical history should be updated for each new ‘course’ of treatment or when the patient re-attends after the agreed recall interval. It should also be updated if the practice is advised of a change to the medical history in the intervening period.

The patient should complete a new medical history proforma every 12 months, with written updates recorded in the notes at each update.

It should be noted that the absence of an up-to-date medical history means that you do not have valid consent to treat the patient, as you are not in possession of all the relevant information that would enable you to explain the pros and cons of all treatment options to the patient.

Relevant previous dental history

Previous dental history that may impact the patient’s current treatment needs should be recorded. This includes such things as:

Date of last visit to a dentist
Whether they are regular or irregular attenders
Details of any problems or complex treatments, e.g., periodontal treatments (including treatment with a hygienist), complex restorative treatments, e.g. crowns, bridges, implants, orthodontic treatment, oral surgery treatment, any adverse reactions to previous analgesia/anaesthesia
The patient’s perception of their anxiety level
Attitude to dental care, e.g. pain relief only (otherwise, do not perceive a need to attend), their views on the aesthetics of their teeth, commitment to a preventive approach, etc.

Relevant social, behavioural or family history

Relevant social and behavioural history includes potential risk behaviour such as smoking, excessive use of alcohol, high sugar consumption, fizzy drink consumption and other potentially erosive behaviours, such as betel nut or tobacco chewing.

Relevant family history includes a family history of periodontal disease or siblings of children with a known high decay rate.

Reason(s) for attendance

Details of the reason or reasons the patient is attending should be recorded, and it is beneficial to record this mainly in the patient’s own words. If the patient has no presenting complaint, this should also be recorded.

Below are several examples of clinical recordings. Dentists who choose to add an added dental interpretation to what the patient has said should ensure they do not change the meaning or emphasis of it.

Extra-oral clinical examination

Details of the following should be recorded:

E/O appearance, including facial asymmetry or abnormal colouration
Facial swellings
Lymph nodes
TMJ

Both positive and negative findings should be recorded. If there are no abnormalities, an entry that states E/O – NAD is acceptable.

Intra-oral clinical examination

Details of the following should be recorded:

Soft tissue examination – record positive and negative findings. Any abnormal or suspicious lesions should be recorded on a mouth map, including the size, shape, colour and texture.
Hard tissue examination including:
- A full dental charting of the teeth present.
- Restorations (including material used)
- Caries (presence and location)
- Missing teeth
- Prostheses (including veneers or inlays, crowns, bridges, dentures and implants)
- Endodontically treated teeth.
- Teeth that should be ‘watched’ but do not currently require restorative intervention.
- Tooth wear
- Mobility
- Significant malocclusions and
- Treatment required.
Examination of the periodontal tissues to include:
- A Basic Periodontal Examination (BPE)
- More detailed records dependent on the BPE scores

Radiographic findings

The following must be recorded:

Justification for the exposure
All radiographic findings (caries, bone levels, widening of periodontal membrane space, radio-opacities, endodontic treatments, unerupted teeth if needed for orthodontic assessment or if past their expected eruption date)
No abnormal findings (can be recorded as NAD)
A quality assurance rating denoting diagnostic value

Note – It is a legal requirement to record these radiographic findings.

Special tests

The following should be recorded if relevant:

Vitality tests
Percussion tests
Pathology tests

Differential diagnosis

A differential diagnosis should be recorded for all presenting complaints and any clinical findings such as periodontal disease, malocclusion, adverse radiographic findings, etc.

Discussions and advice given.

The following should be discussed with the patient, and a record of both the discussion and the outcome should be recorded:

Diagnosis
All alternative treatment options for a given problem
Any risks associated with the options discussed.
The likely longevity of a restoration or procedure (care should be taken that this is not stated as, nor could it be interpreted as, a guarantee)
Any potential consequences of choosing to do nothing.
What the patient must do and agrees to do themselves to care for their oral health and/or any proposed restoration or procedure
Any treatment declined.

Treatment plan

A treatment plan has several functions.

It should:

Be a record of what treatment has been agreed with the patient and any associated risks
Detail the costs of the treatment decided upon.
In chronological order what treatment is required according to the treatment cascade.
Be signed by the dentist and the patient to demonstrate valid consent.

NICE guidance and the recall examination

A great deal of information is required at the new patient examination, and if properly recorded at this stage, the recall examination is an update of previously recorded information.

The recall interval should be determined using a balanced approach that follows NICE guidance and considers the risk factors and the patient’s preference.

BPE

All patients should have a BPE score at every examination appointment. The BPE score will act as a guide as to what treatment is required. Records of the periodontal therapy undertaken should reflect the treatment relevant to the patient’s BPE score. Hygienists and therapists are registered dental care professionals and, as such, have the same record-keeping responsibilities as a dentist. Dentists have a shared responsibility for the patient’s periodontal therapy if the treatment is undertaken by a hygienist or therapist and, as such, should ensure that the hygienist or therapist also keeps good patient records.

Periodontal therapy

A treatment plan for periodontal therapy should be agreed upon from records made at the examination stage. Depending on the diagnosis, the patient may require various types of treatment, either from a hygienist, a therapist or a dentist. Depending on their response to initial therapy, they may also require referral to a periodontal specialist

Fillings

The following should be recorded:

Details of the local anaesthetic used, including amount administered, site and type of LA used
The tooth notation
The filling notation, e.g. MOD, MO, DO, etc.
The amount of caries present (if relevant) and whether the finished preparation is caries-free or not
The amount of remaining tooth tissue
The depth of the cavity (if relevant)
The filling material used together with any special techniques such as bonding.
Any adverse occurrences that happened during tooth preparation or filling
Any advice or warnings given to the patient.

Crown or bridge

The following should be recorded:

Details of the local anaesthetic used, including amount administered, site and type of LA used
The tooth notation
The type of restoration (crown or bridge)
The impression material used.
How the occlusion was recorded
Details of temporisation
Any adverse occurrences that happened during the procedure
Any advice or warnings given to the patient.
Details of the laboratory used.
The date for the appointment to fit the restoration.

Root filling

The following should be recorded:

Details of the local anaesthetic used, including amount administered, site and type of LA used
The tooth notation
The reason the tooth is being endodontically treated
Placement of rubber dam (or not if RD is not used)
The method of gaining access
Whether the pulp is necrotic or hyperaemic
The method used for cleaning the canals.
Any medicaments used.
The method and agent used for irrigating the canals.
The method and materials used for obturation.
Details of temporisation
Any adverse occurrences that happened during the procedure
Any advice or warnings given to the patient.

Denture

The following should be recorded for an existing denture:

Type of denture (full or partial, and if partial, which teeth it replaces)
The material the denture is constructed from (acrylic, chrome/cobalt or other)
An assessment of the retention (e.g. good, satisfactory, adequate or inadequate)
An assessment of the stability
An assessment of the occlusion
An assessment of the freeway space
If a partial denture, any periodontal or caries consequences

The following should be recorded if a new denture is being constructed:

The reason a new denture is desirable.
The patient’s expectations, together with any discussion about whether or not these are realistic.
Details of the primary impressions
Details of secondary impressions and type of special tray
Details of the bite registration (and facebow if used)
Details of the prosthetic teeth selected (make, size, shape, colour)
Details of the try-in appointment, together with a note on whether or not the patient is satisfied at this stage and any adjustments needed for a retry (if relevant)
Details of the retry appointment (if relevant)
Details of the fit appointment and whether or not any adjustments are made in the chair

Extraction

The reason for the extraction and evidence of valid consent
Details of the local anaesthetic used, including amount administered, site and type of LA used.
The tooth notation
A note that haemostasis has been achieved before discharging the patient.
Post-operative instructions were given.
Any adverse occurrences that happened during the procedure
Any other advice or warnings given to the patient

Surgical procedure

The reason for the surgical procedure and evidence of valid consent
Details of the local anaesthetic used, including amount administered, site and type of LA used.
A detailed description of the procedure
Type and number of sutures
A note that haemostasis has been achieved before discharging the patient.
Post-operative instructions given.
Any adverse occurrences that happened during the procedure
Any other advice or warnings given to the patient.

Radiographs

Different pieces of legislation govern the taking, storage and retention of radiographs, and there is some overlap.

The Ionising Radiation Regulations 2017 and the Ionising Radiation (Medical Exposure) Regulations 2017 (IRMER) control the use of radiographs in dentistry. These regulations stipulate several requirements that impact clinical record keeping.

Radiographs are a vital adjunct to good patient care and aid diagnosis and during some treatments, such as endodontic treatment. They should also be taken prior to undertaking certain restorative treatments such as crowns, bridges or veneers, extractions or surgical treatments, orthodontic treatment, and periodontal therapy.

CGDent (formerly FGDP) published criteria for prescribing radiographs entitled ‘Selection Criteria for Dental Radiography’, which should form the basis for all radiographic prescribing in dentistry. Practitioners who fail to follow this guidance and continue to prescribe ‘routine’ bitewing radiographs every 2 years risk having their decision challenged during audit visits.

Dentists are responsible for ensuring they understand and comply with all the legislation governing radiography in dentistry.

The regulations require:

Justification of all radiographs
Optimisation – does not need to be recorded.
A written clinical evaluation
Quality assessment

How should these things be recorded?

Justification

There must be a valid reason for all radiographic exposures. Often, this will be obvious, and no specific comment in the notes is required, e.g. working length radiographs for endodontic treatment or before extraction, etc. If the reason for taking the radiograph(s) is not obvious, then the justification should be recorded. For example, if it is only 18 months since the last bitewings were taken and the patient has few restorations and no pocketing over 3mm, then a written justification would be required because this would appear to be going against the CGDent guidelines. E.g. 2 Bitewings are required as the patient reports recent excessive consumption of fizzy drinks. The prescribed radiographs are justified in this situation, but this is not obvious until the new clinical information is known.

A written clinical evaluation

Clinical findings should be recorded for all radiographs.

Examples:

Caries LL6, UR7. Bone loss as charted.
Short root filling UR5 canals appear sclerosed, with no apical pathology.
UR1 radiolucent area 3mm diameter
Also, negative findings should be recorded, e.g. bitewings – NAD

Quality assessment

A principal objective of the employer’s QA programme is to ensure the consistent production of radiographs of adequate quality for diagnostic purposes while minimising patient doses as far as possible. It is, therefore, important to monitor image quality performance on a regular basis, and a simple subjective image quality rating system is proposed to help with this.

The Guidance Notes for Dental Practitioners on the Safe Use of X-ray Equipment recommends a two-point scale for the subjective quality rating of dental radiographs known as A or N.

Quality rating	Basis	Target (percentage of radiographs or CBCT images in sample)
Quality rating	Basis	Digital imaging	Film imaging
Diagnostically acceptable (“A”)	No errors or minimal errors in either patient preparation, exposure, positioning, image (receptor) processing or image reconstruction and of sufficient image quality to answer the clinical question	Not less than 95%	Not less than 90%
Diagnostically not acceptable (“N”)	Errors in either patient preparation, exposure, positioning, image (receptor) processing or image reconstruction which render the image diagnostically unacceptable	Not greater than 5%	Not greater than 10%

All new patients should be asked when they last had radiographs taken, and every effort should be made to retrieve these from the patient’s previous dentist.

Radiographs must be stored safely and retained for the same time as all other parts of the patient record. Analogue radiographs should be mounted and stored within the record in paper-based practices that retain paper records for storing artefacts such as referral letters and other correspondence. Digital radiographs should be stored electronically.

Photographs

Clinical photographs play an increasingly important role in patient record keeping. They are useful for the following:

Before and after images for aesthetic or cosmetic cases
For patient education, especially in the case of periodontal patients where, it is important to demonstrate the problem and its’ cause to the patient
A record of the patient’s presenting clinical status is especially useful if there is likely to be a difference of clinical opinion in an alleged supervised neglect case.

Photographs should be stored and retained for the same time as all other parts of the patient record. They should either be stored electronically or as part of the paper record.

Study models

Study models are essential for planning and analysis in a number of clinical situations. These include:

Orthodontics
Restorative cases
Aesthetic cases
Implant cases
Record of tooth wear
Occlusal assessments

Study models form part of the patient’s record and, therefore, should be retained for the same time as other parts of the record. Storage of study models and diagnostic wax-ups can be problematic as both are bulky items. It is, however, essential that provision is made for the safe long-term storage of these items. Orthodontic practices and practices that undertake a high volume of complex restorative cases are those with the greatest need for storage space.

Diagnostic wax-ups

Diagnostic wax-ups show the patient what can be achieved and should be retained with the study models for the case and for the same time period as other parts of the record.

Correspondence relating to the patient

From time to time and in certain circumstances (such as in the event of a complaint), patients will correspond with their dentist, and the dentist will need to reply. This will either be via email or letter. All such correspondence should be retained in line with the specific retention periods. In the event of a complaint involving litigation, all correspondence relating to this should also be kept as part of the patient’s record.

Paper-free practices will need to find an appropriate method of storing written correspondence (including emails). This can be achieved either by scanning letters and other documentation and then storing this electronically or by practices that still retain paper files even though patient records are kept electronically, which can store written correspondence (including printouts of emails).

Referral letters and replies to referral letters

A referral letter should contain all relevant details to enable the clinician to whom the patient has been referred to contact the patient and to understand what is required. A referral may be for a second opinion or it may be a request for diagnosis and treatment.

The referral letter should include:

The patient’s name, address, contact telephone number, date of birth and gender.

A summary of any relevant medical or dental history (note you must have the patient’s consent to disclose this information in your referral letter)

The reason for referral, including any patient-stated preference for treatment
Whether the referral is for an opinion only or for treatment
An indication of the level of urgency
Whether the referral is made under the NHS or private contract (if the referral is under private contract, then whether the patient has been advised of any likely costs and what these are)
Your name, address and contact telephone number.
Copies of any relevant radiographs or other special tests
Any additional needs the patient may have

The receiving clinician should send a copy of the initial assessment, report and treatment plan to the referring dentist. Occasionally, the receiving dentist may disagree with the request for proposed treatment if they feel it is inappropriate for any reason. In that situation, they should respond to the referring dentist, stating the reasons for their decision.

When treatment proceeds, upon completion, the receiving clinician should send an ‘end of treatment’ letter.

This should contain:

A report on the treatment undertaken
Details of any complications that may have arisen.
What (if any) follow-up is required
Their assessment of the patient’s view of the treatment
Any other information relevant to the success of the patient’s treatment

Letters of referral and all responses also form part of the patient record and should be kept and stored similarly to that described above.

Pitfalls of keeping poor records

Good record keeping is often not seen as integral to good patient care but as a time-consuming inconvenience that detracts from the important business of providing good patient care. Sadly, it is often only when a dentist encounters a problem, either with some form of complaint or where the records are so poor that they are unable to ascertain what treatment has previously been provided or planned for the future, that the dentist comes to understand the importance of keeping complete, accurate, contemporaneous records.

It is also quite widespread practice to write the notes up at the end of the session or, worse still, at the end of the day. Practitioners believe misguidedly that they will remember what their patients said and what they did some hours after the event. Not only is this unrealistic, but it also specifically contravenes the General Dental Council’s requirement to make and keep contemporaneous records, meaning that they must be written at the time of seeing the patient.

A failure to keep good patient records not only means that it is difficult to provide a high standard of patient care but also leaves the dentist in a vulnerable position should a patient have cause to seek legal advice on the appropriateness of a treatment option or the standard of care provided. Without adequate patient records, the dentist places themselves in a position that can be very difficult to defend.

Disposal of health records

As a baseline process, each practice should assess its archived records. Practices should begin the assessment in alphabetical order over several weeks. The practice should separate those records that will be destroyed and those that will require archiving. For practical purposes, those patients who have not attended between 5 and 10 years are those that will be archived until 11 years have elapsed, when they will be destroyed by the practice or data storage company.

If a patient has not attended the practice for 5 years, the practice will need to appraise if the records have reached their minimum retention period of;

For adults 11 years
Children’s records should be retained for 11 years or until the 25th birthday or 26th if the patient was 17 when treatment ended.

If they have, these records should be prepared to be destroyed. Records can be destroyed in-house or by using an external approved company. Destruction should be completed following ISO 15489-1:2016.

The practice will maintain a log of the disposal decisions taken

Disposal/destruction of records log V1..1July2024.doc

This is to ensure that the practice is aware of those records that have been archived or destroyed and are, therefore, no longer available in the practice. If a patient subsequently returns to the practice, a new dental record will be made. Any clinical records that require permanent preservation are transferred to safe storage.

Consent

We may sometimes need to use patient confidential information. Where this is to be done, we must obtain the patient’s consent.

Approval

These procedures have been approved by the undersigned and will be reviewed annually.

It is a fundamental requirement that all the practice’s records are retained for a minimum period for legal, operational, research and safety reasons. The length of time required to retain records will depend on the type of record and its importance to the practice’s functions. A table for recommended retention periods is detailed at the end of this policy.

Records Management Systems Review

The practice will regularly review its records management practices for compliance.

The review will:

Identify areas of operation that are covered by the practice’s policies and identify which procedures and/or guidance should comply with the policy,
Follow a mechanism for adapting the policy to cover missing areas if these are critical to the creation and use of records,
Set and maintain standards by implementing new procedures, including obtaining feedback where the procedures do not match the desired levels of performance and
Highlight where non-conformance to the procedures is occurring and suggest a tightening of controls and adjustment to related procedures.

Record Retention

The retention periods provided are the minimum periods for which records must be retained for health and care purposes. In most cases, it will be appropriate to dispose of records once this period has expired unless the records have been selected for permanent preservation. Organisations must have procedures and policies for any instances where it is necessary to maintain specifically identified individual records or groups of records (clinical or otherwise) for longer than the stated minimum, including:

temporary retention
public inquiries
ongoing access request, for example, where the ongoing processing of an access request cuts over the minimum retention period. It would not be acceptable to dispose of a record that is part way through being processed for an access request because the minimum retention period has been reached.
where there is a continued business need beyond the minimum retention period, and this is documented in local policy

There will be occasions when care specialities will create digital records that have different retention periods. Where records contain personal data, the decision to retain them must comply with UK GDPR. Generally, where there is justification, records may be retained locally from the minimum period set in this policy for up to 20 years from the last date at which content was added.

Moving from paper to digital

Wherever possible, organisations should be moving to digital records. The original paper record guarantees the authenticity of the record; however, it can be hard to audit. Access to the record, depending on where this is stored, because paper records do not have automatic audit logs. Storage of paper records also will incur costs, whether in-house or offsite. This cost will only increase as the size of the holding or the length of time they are stored increases. Where possible, paper records management processes should be as environmentally friendly as possible. Examples include the shredding of paper records and the end product used for recycling purposes instead of burning records in industrial furnaces.

Destruction of digital records

Destruction implies a permanent action. For digital records, ‘deletion’ may not meet the ISO 27001 standard, as the information can or may be able to be recovered or reversed. Destruction of digital information is, therefore, more challenging. If an offsite company is used, the health and care organisation, as the controller, should check with the ISO whether the provider meets the necessary requirements, similar to the process for the destruction of paper records. One element of records management is accounting for information, so any destruction of hardware, hard drives or storage media must be auditable with respect to the data they hold.

Destruction of paper records

Paper records selected for destruction can be destroyed, subject to following ISO 15489-1:2016. Destruction can be conducted in-house or under contract with an approved offsite company. If an offsite company is used, the practice organisation, as the controller, is responsible for ensuring the provider chosen to carry out off site destruction meets the necessary requirements and can evidence this. This evidence should be checked as part of due diligence (for example, if the provider says they have the ISO accreditation, then check with the ISO). Other diligence activities, such as a site visit to the contractor, should also be carried out. Destruction provider companies must provide a certification of destruction for the bulk destruction of records. This certification must be linked to a list of records so organisations have clear evidence that records have been destroyed. Records that do not contain personal data or confidential material can be destroyed less securely (such as confidential waste bins that do not provide certificates of destruction). If in doubt, the material should be treated as confidential and evidentially destroyed. Do not use domestic waste or put records on rubbish tips to destroy identifiable, confidential material because they remain accessible to anyone who finds them. The British Security Industry Association (BSIA) has provided guidance on information destruction.

When personnel files are held in paper or computerised format, they are subject to data protection legislation. You must be aware of the restrictions on disclosing and accessing such data. Employees have the right to access their records, and you are responsible for ensuring that the data is accurate. Before you release their data to a third party, you must seek permission from that individual; a consent form can be obtained from the DCME compliance portal.

Personnel files and training records, including disciplinary and working time records, should be kept for 6 years after the employment ceases.

It is recommended to retain clinical records for 11 years unless the treatment is complex or particularly difficult for patients, in which case for up to 30 years. Any other records related to patients’ clinical records, including information about drugs supplied to them, laboratories used for prosthetic work, and patient complaint details, should be kept for a minimum of 10 years.

Business records, as well as VAT records, should be kept for a minimum of 6 years.

PAYE, NI and payroll records, SSP and SMP must be kept for at least three years according to HMRC, although the general recommendation is 6 years.

Employers’ liability insurance certificates should be kept for 40 years. Health and Safety risk assessments should be retained permanently. COSHH risk assessments should be kept for at least 5 years.

We also recommend keeping certain training records, such as Continuing Professional Development and Clinical Governance records, for 5 years after you retire to ensure that you have them handy should the need arise.

With digital storage, it is possible to scan and store documents indefinitely, consider this as an option for all documents.

Terms of use are written in general terms and are believed to be based on the relevant legislation, regulations and good practice guidance. This information is indicative only and is intended as a guide for you to review and take professional advice to suit your circumstances.

Working casts and models

Working casts, and study models can be problematic to store. Ideally, they would all be kept indefinitely or scanned with a 3D scanner before recycling. If you do not have a scanner, you could consider storage or scanning with a third-party company. If there is litigation, the possession of a model may help you to defend a case. You may decide to give working casts and models from crown and bridgework to the patient for safekeeping. If you do so, provide a protective model box and record what has been done on the clinical records.

It is advisable to keep implant casts until the treatment has been completed and the patient is satisfied. However, this does not mean that a patient won’t subsequently complain if they have a problem later on. Giving the models to your patients can relieve a storage problem, but you will lose control over what could be an essential piece of evidence in the future. For this reason, the general advice is to keep as many of the models as you can for as long as you can.

Retention Periods

Patients

Record	Retention period	Reference & Info Source
Accidental exposure to radiation report Exposure dosimetry records	30 years (or until the person has reached the age of 75, if longer) 60 years (or until the person has reached the age of 75, if longer)	The Ionising Radiations Regulations 2017 HSE
Appointment books	2 years after the year to which they relate. Diaries of clinical activity and visits must be written up and transferred to the main patient record. If the information is not transferred from the diary, so the only record of the event is in the diary, then this must be retained for 8 years and reviewed. Some staff keep hardback diaries of their appointments or business meetings. If these contain no personal data, they can be disposed of after two years	Records Management NHS Code of Practice 2021
Clinical records, including working casts and models	11 years for adults – England and Wales Children’s records should be retained until the 25th birthday or 26th birthday if the patient was 17 when treatment ended.	Scotland Records Management Code of Practice 2020 DoH, NHS, SDCEP, Northern Ireland DH, HIW
FP 17s	11 Years	NHS Record Management Code of Practice 2021
Complaints records (patients)	NHS England – 10 years	NHS Record Management Code of Practice 2021
Dental Lab Statement of Manufacture of Dental Appliance	10 years	The Medical Device Regulation GDC
Friends and Family Test Response Cards/digital responses	2 years
Subject access requests	3 years	NHS Record Management Code of Practice 2021
Subject access requests where there has been an appeal	6 years	NHS Record Management Code of Practice 2021

Service, maintenance and practice logs

Record	Retention period	Reference & Info Source
Clinical Audit Records	5 years	NHS Record Management Code of Practice 2021
Autoclave Records (Note: photocopy steriliser print outs)	A minimum of 2 years	Pressure Systems Safety Regulations 2000 CQC, HTM 01-05
Compressors, fire equipment inspection	2-3 years	Provision and Use of Work Equipment Regulations (PUWER) 1998 HSE
Controlled drugs invoices (Schedules 2-5)	2 years	Misuse of Drugs Regulations 2001
COSHH risk assessments	5 years from the date of the assessment	The Control of Substances Hazardous to Health Regulations 2002 (COSHH)
Fridge temperature records	Min 1 year (For the life of any products stored within)	Recommendations for the retention of pharmacy records
Health and safety risk assessment	Indefinitely, updated regularly	Management of Health and Safety Work Regulations 1999 HSE
Employers’ liability insurance certificate	40 years	The Employers’ Liability (Compulsory Insurance) Regulations 1998
Portable appliance inspection and testing	3 years	CQC (England)
Infection Prevention Audits	Minimum of 2 years, kept on the premises.	HTM 01-05
Washer-disinfector log books and records	A minimum of 2 years	HTM 01–05
Waste records (hazardous): consignment notes and consignee returns.	3 Years	HTM 07-01
Waste records (Non-hazardous): Waste Transfer Notes	2 Years	HTM 07-01
Water safety records related to legionella risk management	Min 5 Years	HTM 04-01, the Approved Code of Practice L8, HTM 01-05
Daily infection prevention checklists	2 years
Emergency Drugs and Equipment Record	2 years
X-ray equipment test results	The life of the equipment
Privacy Notices	5 years	Scotland Records Management Code of Practice 2020
DPIA	6 years	NHS Record Management Code of Practice 2021
Record Destruction Register	Permanent	Scotland Records Management Code of Practice 2020
National Safety Alerts	Permanent	Scotland Records Management Code of Practice 2020

Financial

Record	Retention period	Reference & Info Source
Accounting records	3 years for private companies, 6 years for public limited companies	Companies Act 2006, CIPD, HMRC
Dental laboratory invoices	6 years is recommended
VAT records	6 Years	VAT notice 700/21 HMRC

Staff records

Record	Retention period	Reference & Info Source
DBS/CRB Criminal records check certificates copy.	NEVER HOLD THE ORIGINAL ON-SITE- TAKE A PHOTOCOPY OF THE TOP AND GIVE IT BACK TO THE INDIVIDUAL	GOV Website, DBS, ICO Certificate number and disclosure level can be retained
Occupational health records	Keep until the 75th birthday or 6 years after the staff member leaves, whichever is sooner.	NHS Record Management Code of Practice 2021
A pre-employment health screening questionnaire	Keep until the 75th birthday or 6 years after the staff member leaves, whichever is sooner.	NHS Record Management Code of Practice 2021
Income tax and NI returns, income tax records and correspondence with the HMRC	Not less than 3 years after the end of the financial year to which they relate. 6 years are recommended.	The Income Tax (Employments) Regulations 1993 (SI 1993/744) CIPD
Statutory Maternity Pay records, calculations, certificates (Mat B1s) or other medical evidence	3 years after the end of the tax year in which the maternity period ends.	The Statutory Maternity Pay (General) Regulations 1986 (SI 1986/1960) Scotland Records Management Code of Practice 2020 CIPD, HMRC
Statutory Sick Pay records, calculations, certificates, self-certificates	The Statutory Sick Pay (Maintenance of Records) (Revocation) Regulations 2014 (SI 2014/55) abolished the former obligation to keep these records. Although there is no longer a specific statutory retention period, employers must keep sickness records to best suit their business needs. Six months after the end of the period of sick leave is sensible in case of a disability discrimination claim. For personal injury claims, the limitation is 3 years. If there’s a contractual claim for breach of an employment contract, keep records for 6 years after the employment ceases. Employers should keep a record of SSP paid due to COVID-19, as HMRC may request records.	The Statutory Sick Pay (Maintenance of Records) (Revocation) Regulations 2014 (SI 2014/55) CIPD, HMRC
Health surveillance records If you cease to trade, notify HSE in writing and make the records available to them.	40 Years	The Control of Substances Hazardous to Health Regulations 2002 (COSHH) CIPD, HSE
Wage/salary records, overtime, bonuses, expenses	At least 3 years after the end of the tax year to which they relate. However, 7 years after employment may be justified.	Taxes Management Act 1970 CIPD
Application forms and interview notes (for unsuccessful candidates)	6-12 months	CIPD
Parental leave	18 years from the birth of the child	CIPD
Personnel files and training records (including disciplinary records and working time records)	6 years after employment ceases	CIPD
Redundancy details, calculations of payments, refunds, notification to the Secretary of State	6 years from the date of redundancy	CIPD
CPD records	5 years after the end of your CPD cycle	GDC – CPD for dental professionals
Whistleblowing documents	6 months following the outcome (if a substantiated investigation). If unsubstantiated, personal data should be removed immediately.	Public Interest Disclosure Act 1998 CIPD

Other

Record

Retention period

Reference & Info Source

Accident books

Accident records/reports

RIDDOR reports

3 years after the date of the last entry

3 years for each report

5-6 years to allow for litigation

The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)

CIPD, HSE