The document provides guidelines for maintaining proper patient records in endodontics. It outlines the important components of endodontic treatment records, including patient information, medical and dental history, diagnostic tests, treatment plans, informed consent forms, progress notes, and radiographs. Maintaining accurate, comprehensive records is essential for providing quality patient care, documenting treatment, and meeting legal and professional obligations.

1. PATIENT RECORDS IN
ENDODONTICS
Dr. V. Vasundhara
2nd year pg
Dept of conservative dentistry and
endodontics.

2. CONTENTS
 Introduction
 Importance of dental records
 Contents of endodontic treatment records
 Patient information form
 Medical health history
 Dental history
 Diagnosis and progress records
 Radiographs
 Evaluation and diagnosis
 Diagnostic test
 Treatment plan
 Informed consent

3.  General principles applied
 Content and standards for record keeping
 Contents of dental records
 Clinical details
 Improving records
 Storage and security
 Electronic records
 Retention of records
 Access to records
 confedentiality
 record size

4.  Patient record request
 Patient education pamphlets
 Postoperative instructions
 Recording referrals
 Record correction
 Legal responsibility
mal prophylaxis: importance of record
standard of care for endodontics
 Forensic use of dental records
 Conclusion
 references

5. Introduction
A dental record is the detailed document of the history of the
illness, physical examination, diagnosis, treatment, and
management of a patient.
Dental professionals are compelled by law to produce and
maintain adequate patient records. With the increasing awareness
among the general public of legal issues surrounding healthcare,
and with the worrying rise in malpractice cases, a thorough
knowledge of dental record issues is essential for any practitioner.
The ability of clinical practitioners to produce and maintain
accurate dental records is essential for good quality patient care
as well as it being a legal obligation.

6.  The dental record provides for the continuity of care for the
patient and is critical in the event of a malpractice insurance
claim.
 It should be written with the involvement of the patient or client
wherever practicable and completed as soon as possible after
an event has occurred. It should provide clear evidence of the
care planned, the decisions made, the care delivered and the
information shared’.

7. FUNCTION
Dental records should document the following information:
1. Course of the patient's dental disease and treatment by
recorded diagnosis, treatment, and prognosis.
2. Communication among the treating dentist and other health
care providers, consultants, subsequent treating practitioners,
and third-party carriers.
3. Official professional business record in dental-legal matters
documenting a sound plan of dental management.
4. Necessity and reasonableness of care and treatment for
evaluation by peer review and insurance carriers.
5. The standard of care was followed.

8. WHY MAKE AND RETAIN RECORDS?

9. Dental records play an essential role in:
(a) documenting the consent provided by the patient;
(b) documenting the assessment and treatment of the patient;
(c) documenting the advice provided to the patient;
(d) assisting with complaint resolution, medico-legal and
professional standards reviews; and
(e) documenting compliance with insurer, other third party payer
and government subsidized dental program requirements.

10.  A record of each occasion of service for a patient is an
essential part of the practice of dentistry.
 This improves diagnosis, treatment planning, case
management and practice administration.
 Accurate records assist efficient and complete delivery of
care in the event of another clinician assuming that patient’s
treatment.
 Patient records form the basis for retrieval of treatment details
in the case of a dispute or the requirement to provide
evidence.
 It is desirable that such details provide an adequate
contemporaneous record that obviates the need for any later,
and possibly questionable, assumptions that a dentist’s ‘usual
practices’ were followed in a specific case.

11. ENDODONTIC TREATMENT RECORDS SHOULD
INCLUDE..
 Name of patient
 Date of visit
 Medical and dental history
 Allergies and adverse drug reactions
 Chief complaints
 Radiographs of diagnostic quality
 Pulpal and periodontal tests performed
 Clinical examination findings
 Differential and final diagnosis
 Treatment plan prognosis
 Referrals, including patient refusal (if any)
 Communications with other health care providers

12.  Progress notes
 Completion notes
 Cancelled or missed appointments and stated reasons
 Emergency treatment
 Patient concerns and dissatisfactions
 Planned follow ups
 Drugs and laboratory prescriptions
 Patient non compliance
 Consent forms
 Accounting
 Recall notifications
 E-mail address
 phone number

13. PATIENT INFORMATION FORM
 A patient information form provides data essential for
identification and office communication. Name, address,
business address, and telephone numbers arc needed to
contact the patient for scheduling purposes or to inquire about
postoperative treatment sequelae.
 In the event the patient is a minor, the responsible parent or
guardian should provide the information
 dental insurance and financial responsibility are included to
avoid any misunderstandings later and to fulfill federal
requirements regarding truth in lending law, applicable if four or
more installment payments are arranged. Patient information
and history forms should be updated periodically

15. MEDICAL HEALTH HISTORY
 Past and present health status should be thoroughly reviewed
by the dentist before proceeding so that dental treatment can
be safely initiated
 Health questionnaires open avenues for discussion about
problems of major organ systems, important biochemical
mechanisms, such as blood coagulation, and any
immunocompromised need for antibiotic prophylaxis, and
disease susceptibility.

16. the following checklist may be helpful:
• details of past hospitalizations and/or serious illnesses,
conditions or adverse reactions;
• significant respiratory diseases, e.g. asthma, emphysema,
tuberculosis;
• any known allergies;
• peculiar or adverse reactions to any medicines or injections, e.g.
penicillin, Aspirin or local anaesthetics;
• heart disease, heart attack, blood pressure problems or stroke;
• history of infective endocarditis;
• epilepsy or seizures;
• blood disorders, bleeding or bruising tendency;
• endocrine disorders, e.g. diabetes;
• cancer/radiation treatment/chemotherapy;

17. • hepatitis A/B/C, jaundice, liver disease or gastrointestinal
disorders;
• kidney disease; immuno-compromising diseases, e.g. HIV
positive status, AIDS, leukemias;
• nutritional status/eating disorders, e.g. anorexia nervosa,
bulimia;
• any prosthetic joints;
• medications and supplements taken regularly;
• pregnancy;
• psychiatric disorders/treatment;
• drug or alcohol dependency; and
• any other conditions or problems of which the clinician should be
made aware.
Any drug allergies, medical alerts or conditions pertinent to the
patient’s care should be conspicuously noted in the patient record.

18.  Current medications, medical therapy, and the name and
location of the treating physicians are essential.
 Updating the medical history requires the practitioner to be
apprised of changes in the patient’s medical condition and
new medications the patient is taking, including over-the-
counter or herbal medications and/or supplements.
 Medical histories should be updated periodically.

20. DENTAL HISTORY
 The dental history should include past dental difficulties, name
and address of current or most recent treating clinician, chief
complaint, relevant prior dental treatment, and attitude
regarding teeth retention.
 A positive response should suggest further consultation with
the patient and consideration for obtaining the prior treating
dentist's written records and radiographs for elucidation

22. DIAGNOSTIC AND PROGRESS RECORDS
 Diagnostic and progress records often combine the "fill-in“ and
"check-off" types of forms. Fill-in or essay-type forms allow
greater latitude of response to a question, resulting in a more
detailed description.
 One drawback, however, is that it also is open to oversights
unless a dentist is very conscientious in noting all clinical
information.

23.  An essay-type health history response, alone, is insufficient.
Often a patient may not appreciate the significance of
important symptoms.
 A check-off format is efficient and more practical. such records
document missing medical information the patient failed to
provide. Therefore, at the end of the check-off portion of the
medical history, there should be an essay question so that the
patient can provide any other pertinent medical information.

24. RADIOGRAPHS
 Radiographs arc essential for diagnosis and also as additional
documentation of the pretreatment condition of the patient.
 Diagnostic quality periapical radiographs are essential aids in
diagnosis and midtreatment endodontic therapy, to verify the
final result, and for follow-up comparisons at recall
examinations.

25. EVALUATION AND DIAGNOSIS
 Diagnosis includes discussing history of the current problem,
clinical examination, pulpal testing, and recorded radiographic
results. If therapy is indicated, the reasons can be discussed
with the patient in an organized way. When other factors affect
the prognosis (e.g., strategic importance or restorability of the
tooth),
 the clinician should consider further consultation before
initiating any treatment.

26. DIAGNOTIC TESTS
 The following endodontics tests should be performed to arrive
at a correct and accurate endodontic diagnosis:
 Percussion
 Thermal testing
 Electric testing palpation
 Mobility
 Periodontal assessment
Reasonable clinicians should record all testing results, both
positive and negative.

27. TREATMENT PLAN
 All treatment provided on a given date is documented by
placing a check mark within the designated procedural
category.
 Individual root canal lengths are recorded by
1. Circling the corresponding anatomic designation and the
method of length determination.
2. Writing the measurement (in millimeter) and
3. Indicating the reference point.
For any medication prescribed, refilled, or dispensed, the
treatment record should show the date and type of drug.
periodic recall intervals, dates and findings are entered in
the spaces provided.
e-mail prescriptions and correspondence should be
documented with hard copies in the chart or stored in electronic
format.

28. INFORMED CONSENT FORM
 After endodontic diagnosis, the benefits, risks, treatment plan,
and alternatives to endodontic treatment, including the
patient's refusal of treatment, are presented to the patient or
guardian. This will document acceptance or rejection of the
consultation recommendations.
 The patient (or guardian) signs and dates the consent form,
including any video informed consent.
 subsequent changes in the proposed treatment plan should
also be discussed and initialed by the patient, to indicate
continued acceptance and to acknowledge understanding of
any new risks, alternatives, or referrals.

29.  To obviate a patient’s claim that no explanation ever occurred,
a patient questionnaire can additionally be used. Patient can
be instructed that unless they score 100%, proposed
procedure will not be done.

31. GENERAL PRINCIPLES TO BE APPLIED
(a) Clinically relevant, accurate, contemporaneous records are
essential to provide dental care and for forensic purposes.
(b) Dentists should take reasonable steps to ensure that the
information in dental records is accurate, complete and up to
date.
(c) Dentists are only permitted to collect information which is
necessary for their lawful functions and activities.
(d) Records must be sufficiently comprehensible in each entry so
that another practitioner, relying on the record, can undertake
the patient’s ongoing care.
(e) Dental Records should be completed as soon as practicable
after the service has been rendered by the dentist.

32. (f) Entries should be made in chronological order.
(g) Entries must be accurate and should be concise.
(h) Dental records must be understandable by third parties,
particularly other health care providers. Records should be
legible and abbreviations standard ones.
(i) Dental records must be able to be retrieved when required.
(j) All comments must be provided based upon the facts, do not
include emotional language or make defamatory statements.
k) A treating dental practitioner must not delegate responsibility
for the accuracy of medical and dental information to another
person.

33. (l) The treating dentist should ensure that only authorised and
suitably qualified persons provide clinical information from the
dental record to patients and other persons.
(m) Records should be kept for each patient contact.
(n) Dentists should protect the privacy and confidentiality of dental
records and comply with all relevant Privacy Laws.
(o)All entries should be dated and recorded by hand in permanent
ink or typewritten, or be in an acceptable electronic format and be
complete, clear and legible.
(p)All entries, including electronic entries, should be signed,
initialled or otherwise attributable to the writer and if different, the
treating clinician.

34. (q)Radiographs and other diagnostic aids, such as study models,
should be properly labelled, dated and the interpretation of the
findings documented when considered appropriate by the
practitioner.
(r)An explanation of the overall treatment plan, treatment
alternatives, any risks or limitations of treatment and the estimated
costs of the treatment should be provided to each patient, parent,
legal guardian or government-appointed advocate as appropriate.
This fact should be noted in the patient record. In complex or difficult
cases, it is advisable
to have such informed consent signed.
Adopted by ADA Federal Council, November 15/16, 2012
Dental record keeping guidelines, cdsbc

35. CONTENT AND STANDARDS FOR RECORD
KEEPING:
(a) Patient details:
 Sufficient information to identify and communicate with the
patient should be recorded, including:
(i) identifying details of the patient (full name, sex, date of birth
and address, including email and telephone number); and
(ii) the current medical history of the patient, including any
adverse drug reactions.

36. b) Substitute decision maker
 If the patient is a child or under the care of a legal guardian or
substitute decision maker, the dental record should contain
the name, address and contact details of the parent, guardian
or substitute decision maker and the relationship of the
substitute decision maker to the patient.
(c) Consents and restrictions on disclosure

37. THE DENTAL RECORD SHOULD INCLUDE:
(i) a record of consents provided by the Patient.;
(ii) if written consent is provided, the signed consent form;
(iii) If a patient information sheet has been provided to the
patient, a copy of the patient information sheet or reference to
the name and version/date of the patient information sheet;
(iv) if written consent is not provided, then:
(A) a description of the treatment as explained to the
patient; and
(B) the consents provided by the patient, including
consent to treatment, privacy consents and financial consent;

38. (v) advice given to the patient on:
(A) treatment options;
(B) the relevant material risks and benefits of those
options;
(C) pre- and post-treatment instructions;
(D) likely outcomes;
(vi) relevant questions, comments or concerns expressed by
patients over offered treatments;
(vii) any treatment advice that the patient was unwilling to
accept;
(viii) any comments or complaints by patients about treatment
provided;
(ix) if there are any restrictions on disclosures, including in
relation to any directions from the patient or family law
restrictions;

39. (x) if the patient has made a direction in relation to care, such as
a restriction on blood transfusions, etc;
(xi) subject to discrimination laws, for workplace health and
safety reasons, you may wish to include a “flag” on the medical
record for the treating provider within your dental practice to
contact you, for example, if a patient has previously displayed
aggression or inappropriate behaviour towards staff so that
appropriate staff can be involved in treating the patient;
(xii) if English is not the patient’s first language, if an interpreter
is required to treat the patient.

40. CLINICAL DETAILS:
 clear documentation describing:
(A) the date of visit;
(B) the identifying details of the practitioner providing the
treatment;
(C) information about the type of examination conducted;
(D) the presenting complaint;
(E) relevant history;
(F) clinical findings and observations;
(G) diagnosis;
(H) treatment plans and alternatives;
(I) consent of the patient, client or consumer;
(J) all procedures conducted;

41. (K) instrument batch (tracking) control identification, where
relevant
(L) a medicine/drug prescribed, administered or supplied or any
other therapeutic agent used (name, quantity, dose,
instructions);
(M) details of advice provided

42. Other details
 all referrals to and from other practitioners;
 any relevant communication with or about the patient, client
or consumer;
 details of anyone contributing to the dental record;
 estimates or quotations of fees.
 Records should also indicate when the patient failed to attend
and provide for adequate follow up

43. How to improve record-keeping?
 By adopting the following habits, nurses should avoid problems
related to record-keeping:
 - Get into the habit of using factual, consistent, accurate,
objective and unambiguous patient information;
 - Use your senses to record what you did, such as ‘I heard’, ‘felt’,
‘saw’, and so on;
 - Use quotation marks where necessary, such as when you are
recording what has been said to you;
 Ensure there is a reasoned rationale (evidence) for any decision
recorded, for example, denying access to a visit from children;
 - Ensure notes are accurately dated, timed, and signed, with the
name printed alongside the entry (initials should be avoided);

44.  Follow the SMART model (Specific, Measurable, Achievable,
Realistic and Time-based) or similar when planning care;
 - Write up notes as soon as possible after an event and, by
law, within 24 hours, making clear any subsequent alterations
or additions;
 - Document any objections you may have to the care that has
been given;
 - Do not include jargon, meaningless phrases (for example
‘slept well’), irrelevant speculation, and offensive subjective
statements;
 - Write the notes, where possible, with the involvement and
understanding of the patient or carer .

45. STORAGE AND SECURITY OF RECORDS
 Dental practices must take reasonable steps to protect the
personal information it holds from misuse and loss and from
unauthorised access, modification or disclosure.
 Dental records should be securely stored, protected from
unauthorised access or use. All file cabinets should be locked
and kept in a room which is not accessible to the general
public.
 All computers should be password protected. Information
technology systems should have appropriate security software
installed.
 Dentists should ensure records are maintained on durable
paper, some forms of medical photographic imaging fades
with time and should be copied.

46.  Dental records can be sent by secure fax or email. When
sending dental records by post, traceable methods should be
used such as registered mail or express post.
 If a health record is destroyed after the required retention
periods, it must be destroyed in a secure manner, such as
document shredding.

47. ELECTRONIC RECORDS
It is important that any electronic recordkeeping system employed
in a dental practice:
has a login and password to access the data, or otherwise provide
reasonable protection against unauthorized access, and can
authenticate all entries;
provides an accurate visual display of the recorded information and
is capable of retrieving and printing this information within a
reasonable time period;
• has an audit trail that:
–– records the author, time, date, workstation (for networked
systems) of each entry for each patient with respect to the clinical
or financial data entry, and is capable of being printed separately
from the recorded information for each patient;

48. preserves the original content of the recorded information (text,
image or chart) in a readonly format that when changed or updated
tracks the author, time, date, and workstation (for networked
systems) of the modification;
provides a means of visually displaying the clinical and financial
records of each patient by patient name and is easily printed or
transferred with the inclusion of all of the original and modified
entries, and the dates, order of entry and authors;
• has the capability to provide good quality printed copies of the
records and digitized images;
• stores the original data in a read-only format from within the dental
program itself, but protects the data files from entry and alteration
from the database;

49. • backs up files on a removable medium that allows data
recovery, or provides by other means, reasonable protection
against loss, damage, and/ or inaccessibility of patient
information; and
• ensures the privacy of the patient’s personal information is
properly safeguarded in both the electronic recordkeeping and in
the transfer of the patient’s records.

50.  Other necessary functional requirements of electronic records
are:
1.a dental practitioner’s records must show who made each
entry and when it was made;
2. it must not be possible for entries to be changed without trace,
that is, there must be an audit trail
3.there should be security procedures such as access being
available only by password
4.there must be a standard procedure for entering treatment
record data that is recorded in an office manual or
memorandum to the practitioner’s staff; and there must be
adequate computer back up and disaster recovery systems in
place

51. RETENTION OF RECORDS

52. Dental records should be retained:
 In the case of health information collected while the individual
was an adult – for at least seven years from the last occasion on
which a health service was provided to the individual by the
health service provider;
 in the case of health information collected while the individual
was under the age of 18 years – at least until the individual has
attend the age of 25 years.

53. 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 it and the date on
which is was deleted or disposed of.
A health service provider who transfer health information to
another organisation and does not continue to hold a record of
that information must keep a record of the name and address of
the organisation to whom or to which it was transferred
A health record may be kept in electronic form, but only if it is
capable of being printed in paper.

54.  Unless required by law, or an agreed transfer of records to
another treating practitioner, copies and not originals of
records should be released. If original records are released,
dental practitioners should obtain an acknowledgment receipt
and also retain copies for their own records.
 Diagnostic images and reports should be kept as part of the
dental record. It is a reasonable alternative that diagnostic
images and diagnostic casts be given to the patient for
retention.
 Subject to mandatory retention requirements, dentists must
take reasonable steps to destroy or permanently destroy or
permanently de-identify personal information if it is no longer
needed for any purpose for which the information may be
used or disclosed under Privacy Laws

55. ACCESS TO RECORDS

56.  The dentist (or the dental practice) owns the dental records.
 Copyright in dental records may or may not exist depending
upon the circumstances and the complexity of the entry.
 Under Privacy Laws, if a dentist holds personal information
about an individual (including a patient), it must provide the
individual with access to the information on request by the
individual
 unless a specific exemption applies.

57. The exemptions include:
 In the case of health information, providing access would pose
a serious threat to the life or health of any individual. In this
case, dental records may be provided to another dental practice
to explain to the patient; or the record is covered by legal
professional privilege (which would not apply to ordinary dental
records but may apply to a medico-legal report written by a
dentist).
 Access may include providing the patient with a copy of the
dental records.
 If a dentist charges for providing access to personal
information, those charges: must not be excessive; and must
not apply to lodging a request for access

58.  In some States, the costs are regulated under State Privacy
Laws.
 It is recommended that when a patient seeks to access their
dental records, the dentist offers to meet with the patient and
explain the records to them.
 It is preferable that the information should be provided in a
report, and not simply by sending a copy (never an original,
unless an original is required by court order) of the records. A
report written for the express purpose of the request may be
far more helpful than the records themselves.

59.  If a dentist holds personal information about an individual and
the individual is able to establish that the information is not
accurate, complete and up-to-date, the dentist must take
reasonable
 steps to correct the information so that it is accurate, complete
and up to date.
 If the individual and the organisation disagree about whether
the information is accurate, complete and up-to-date, and the
individual asks the dentist to associate with the information a
statement claiming that the information is not accurate,
complete or up-to-date, the dentist must take reasonable steps
to do so.
 A dentist must provide reasons for denial of access or a refusal
to correct persons information.

60. CONFIDENTIALITY

61. Patient information and dental records contain sensitive personal
information and must be kept in confidence. A patient’s personal
information and dental records must be protected from any
unauthorized use or disclosure, except as required by law or
where the patient has given their express consent, ideally in
writing.
Dentists are also responsible for ensuring that their staff is aware
of the requirement of maintaining confidentiality with respect to
patient information and dental records. Dentists and their staff
must also be aware of the requirement for patient consent before
the disclosure or transfer of any patient information or dental
records to any third party, including to other family members.

62. Confidentiality requirements apply to paper, electronic, and other
forms of patient information and dental records.
Records should be stored securely, not left unattended or in
public areas of the office, and destroyed appropriately and
securely at the end of the required retention period

63. RECORD SIZE
 Although there is little harm in recording too much information,
there is great danger in recording too little. Standard 8 ½ * 11
inch or larger clinical records possess the advantage of
providing the treating clinician adequate space for clinical
notes.

64. PATIENT RECORD REQUEST
 Patient requests for records must be honored. It is unethical to
refuse to transfer patient records, upon patient request, to
another treating clinician.
 Moreover, refusing to provide patient records is illegal in some
states, subjecting the clinician to discipline and fines should
the records not be provided to the patient upon written
request, even if an outstanding balance is owed.

65. PATIENT EDUCATION PAMPHLETS
 Patient education pamphlets may be utilized in litigation as
evidence that a patient who was properly informed and given
endodontic alternatives, instead chose extraction.
 Such pamphlets include the ADA's "Your Teeth Can be Saved
by Endodontic Root Canal Treatment" or the AAE's "Saving
Teeth Through Endodontic Therapy." Indicate in the patient's
chart that the patient was shown or given the pamphlet(s).

66. POST OPERATIVE INSTRUCTIONS
 It is unlikely a patient will remember oral post operative
instructions unless accompanied with written instructions.
 After endodontic procedures, the patient may be sedated or
affected by analgesic drugs. Accordingly, written post
operative instructions are beneficial.
 Emergency phone numbers to contact the treating clinician
should be included on the form.

67. RECORDING REFERRALS
 If consultations with additional experts or specialists become
necessary, referrals should be recorded lest they be forgotten
or refused. Carbonless, two-part referrals cards allow the
clinician to provide an original referral slip to the patient while
retaining a copy for the patient’s chart.
 The clinician or staff member should document the fact that
the original referral card was given to the patient and record
the name of the person who provided the referral card and the
date on which it was provided.
 the clinician should request that the patient and referred
clinician report back if the referral appointment is canceled.

68. RECORD CORRECTION
 Records must be complete, accurate, legible, and dated. All
diagnosis, treatments, and referrals should be recorded.
 To correct an entry, the clinician should make a line through (
but not erase or obscure) the erroneous entry. The correction
should then be written on the next available line and dated.
 If records are proven to be falsified, the clinician may be
subject to punitive damages in civil litigation. In addition, the
clinician may be subject to license revocation for intentional
misconduct.

69. LEGAL RESPOSIBILITIES

70. MAL PRACTICE PROPHYLAXIS: IMPORTANCE
OF RECORDS
 Records represent the single most critical evidence a clinician
can present in court as confirmation that an accurate
diagnosis, proper planned treatment, and informed consent
were provided.
 Prevention is the goal of modern dental care.
 Competent endodontic treatment performed within the
requisite standard of care not only saves endodontically
treated teeth but also helps prevent a lawsuit for professional
negligence.

71. STANDARD OF CARE FOR ENDODONTICS
 Endodontists should not forget their general clinician training.
Even though a patient may be referred for a specific
procedure or undertaking, the endodontist should not over
look sound biologic principles inherent in the overall
treatment.
 Endodontist should not provide rubber-stamp treatment to
whatever the clinician refers or recommends. Without
performing an independent examination, the endodontist risks
misdiagnosis and resulting incorrect treatment.
 Radigraphs from the referring clinician should be reviewed for
completeness, clarity and diagnostic accuracy. An endodontist
should expose a new radiograph to verify current status
before treatment.

72. It is necessary for the endodontist to:
 Be alert to any contributory medical or dental condition within
the operative area of endodontic treatment that can affect
treatment.
 Undertake an independent diagnostic and radioghraphic
examination of the treatment area and the treatment plan
rather relying solely on the referring clinician.
 Perform a general dental examination to diagnose any hard
and soft tissue pathosis.
 Evaluate status and prognosis of adjacent and opposing
teeth.
 Advise the referring clinician and patient of pertinent findings.

73. FORENSIC USES OF PATIENT RECORDS

74.  Dental records also provide valuable ante mortem records to
forensic odontologists. Forensic dentistry is the overlap of
dental and legal professions. Forensic dentists are frequently
called upon to identify the remains of individuals who cannot
be identified visually.
 The identification is usually carried out by comparison of ante
mortem and postmortem records. The identification of
diseased individuals is an essential element in the process of
death certification and is crucial component in the
investigation of homicides or other suspicious deaths.

75. CONCLUSION
 Doubt about what should be documented or how records
need to be kept, practitioners should ask themselves: “Will this
action serve the best interests of my patient? Does this action
helps in my patient’s safety and the continuity of his or her
dental care?”
 The principles applying to handwritten records also apply to
computer records, for example, entries must be date, time,
and operator-stamped, all changes made must be traceable,
and any codes used must be readily convertible to
conventional language.

76.  Records must be readily accessible and understandable data
needs to be controlled, for example, via use of passwords.
 The production, retention, and release of clear and accurate
patient records are an essential part of the dentist’s
professional responsibility. Success in this task will assist the
dentist for a medicolegal claim be made and can assist the
police and coroners in the correct identification of individuals.

77. REFRENCES
 Pathways of pulp cohen tenth edition
 Ingle text book of endodontics 6th edition
 Dental record keeping guidelines, college of dental surgeons of
british columbia april 2013.
 B K charangowda Dental records: An overview J Forensic Dent Sci.
2010 Jan-Jun; 2(1): 5–10
 DENTAL RECORDS (Including ADA Guidelines for Dental Records)