Clinical examination & record-keeping: Part 3: Electronic records

Key Points

  • Discusses the creation and maintenance of electronic records.

  • Advises on security and encryption for electronic records.

  • Discusses the legal aspects of retaining electronic records in practice.

Abstract

This article is the third and final part of a BDJ series of Practice papers on the subject of clinical examination and related record keeping. The series is taken from the Faculty of General Dental Practice UK (FGDP[UK]) 2016 Good Practice Guidelines book on this topic, edited by A. M. Hadden. This particular article covers the creation and maintenance of electronic patient records, including security and encryption guidance. It is important to note that throughout this article (and the BDJ series and associated FGDP[UK] book), the specific guidelines will be marked as follows: A: Aspirational, B: Basic, C: Conditional. Further information about this guideline notation system is provided in Part 1 of this series (BDJ 2017; 223: 765–768).

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References

  1. 1

    Faculty of General Dental Practice (UK). Selection Criteria for Dental Radiography, 3rd edition. London: Faculty of General Dental Practice (UK), 2013.

  2. 2

    Data Protection Act 1998. London: HMSO; 1998. www.legislation.gov.uk/ukpga/1998/29/pdfs/ukpga_19980029_en.pdf.

  3. 3

    Department of Health. Records management: NHS Code of Practice Part 2, Annex D1. London: DH, 2009. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/200139/Records_Management_-_NHS_Code_of_Practice_Part_2_second_edition.pdf.

  4. 4

    https://www.microsoft.com/security/online-privacy/safely-dispose-computers-and-devices.aspx.

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Hadden, A., and the FGDP(UK) Clinical Examination and Record-Keeping Working Group. Clinical examination & record-keeping: Part 3: Electronic records. Br Dent J 223, 873–876 (2017). https://doi.org/10.1038/sj.bdj.2017.994

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