The Dental Board of Australia Guidelines on Dental Records outlines the requirements for Dental Records in Australia. However, this document is brief, and in some cases, open to variance in interpretation. A study published in 2016 provided additional clarity about the standards expected by drawing on the consensus opinion of experts in this field. In this series of articles, we consider what constitutes a complete dental record.
What should be included as part of a relevant history?
Recording a ‘relevant history’ is mandatory according to the Dental Board of Australia, but what should this include? A relevant history is a history provided by the patient, usually relating to the presenting complaint and/or reason for attendance. This should include:
· When the patient first became aware of, or suspected the condition, and any events that corresponded with it starting
· What the patient has been experiencing as a result of the condition
· Whether the patient has experienced the condition before, and the outcome of prior experiences
· Outcomes of any prior diagnostic/ management attempts (including patient self-management)
· What aspects of the medical, dental or social history could be important in the presentation, or management of the condition
From a continuity of care perspective, this information will provide an important baseline of presenting characteristics to which changes in status (either due to intervention or the passing of time) can be compared. Articulating the ‘history of complaint’ in such a structured way can be a useful mediator through a mental diagnostic tree for the clinician to arrive at the most likely provisional diagnoses. This is an excellent foundation for any further diagnostic tests.
An example of why this may be relevant is that the history of the presenting complaint usually supports the diagnosis, and in some cases, is diagnostic in its own right. Therefore, if there becomes any question of whether the diagnosis or treatment were appropriate, the presenting complaint characteristics becomes important.
A practical example of this may be in the situation of a patient having root canal treatment undertaken. If this treatment was to fail, and the patient didn’t feel it was necessary in the first place, the presenting complaint may form an important piece of evidence that justifies the diagnosis and supports other records (such as radiographs, sensibility tests, percussion tests).
An example of a presenting complaint:
T/A #17 (points) started 2/7 ago causing loss of sleep. Spontaneous aching. Abscess 1/12 ago felt similar. Paracetamol TID ineffective. Deep resto here approx.6/12 ago.
Tip: Recording of the presenting complaint may be assisted by a skilled and trained clinical assistant. Although the dental practitioner cannot delegate ultimate responsibility for the accuracy and completeness of the dental record, the dental team can contribute to the draft form of these notes so as to allow the clinician to focus on the conversation with the patient during the initial collection of information.
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