Documentation is of high importance in any medical practice nowadays whether by maintaining manual or electronic records of your patients' medical status and procedures carried out. As a dentist, if you are wondering exactly what are dental clinical notes? Well, a dental note or record is the detailed document of the dental appointment, the history of the illness, physical examination, diagnosis, treatment, and management of a patient. But why do dentists make notes? It is a requirement of the General Dental Council (UK) that all dentists produce and manage patient records appropriately and at the time of treatment. With the increasing awareness among the general public of legal issues surrounding healthcare, and with the worrying rise in malpractice cases in medical or dental care, a thorough knowledge of dental record issues is essential for any practitioner. Not to mention, the importance for dental insurance policies. Regardless of place of dental practice, a good standard of record keeping is essential.

‘Good records facilitate good defense, poor records a poor defense and no records no defense’.

State and federal laws determine how the dental record is handled, how long it is kept, and who may have access to the information.

Electronic or hand records?

Dental patient records should be of high quality, contain information to allow for good continuity of care and clinical defense and, ideally, facilitate clinical audit. Therefore, it is paramount that dental records are of a high standard if this essential aspect of clinical governance is to be carried out and improvements to the standard of patient care made.

Several studies have demonstrated that electronic dental records have a better compliance with the legal regulations. It is believed that changes to increase compliance to 100% would be minimal for electronic digital records, whereas handwritten records would require greater changes and would not necessarily guarantee an improvement in compliance. Adding to that, if asking how to maintain dental records? Electronic records are superior in maintenance and safety. To elucidate, digital records allow for better continuity of care and provide a sound basis for improvements in standard of care by providing a detailed dental record for clinical audit.

An example of a study can be found here:

Computer vs hand-generated clinical notes.

Kiroku was eager to revolutionize the documentation side of dentistry by facilitating record keeping in a digital fast way that aids dentists to meet legal requirements with no errors, minimal time and no effort at all during the dentist appointment.

New patient? No problem!

Plenty ask how do you write good dental notes?

Kiroku is the answer! We have introduced a Comprehensive Exam template that guides any dental specialist through the steps to take during the first appointment process of comprehensive patient care. It is designed for your own personal use whether in public or private practice. Any student dentist could use it too. Let's have a detailed look on the various sections it comprises.

Kiroku, an online form of note taking that offers faster and more detailed documentation than anything you may have tried before!

Throughout the template, you will find:

• Clickable buttons to your templates so you don’t need to highlight and delete text.
• Automatically added discussions and information at the appropriate time.
• Adding text is also available with ease everywhere if needed. Whenever there are button choices, you will always find the button 'Other' that gives a chance to add information not included in the options.

First things first, you start by filling the basic exam appointment details such as your name, the nurse and patient's names with the reason of the visit alongside the chief complaint and the preferred outcome of the patient's dental treatment.

Afterwards, social history is noted which includes 'Smoking, alcohol and stress grade mark'. Special customized discussions are tailor made depending on the buttons you click in this section which will be found in the discussion section of the template.

Moving on, the medical history encompasses health history and medications which can give an idea of the possible chronic diseases that interfere with oral health or your care plans for the patient. You check allergies, medications and conditions by clickable buttons to avoid any case of malpractice.

Here comes the dental comprehensive care part, commencing with the dental history where the primary dental health care provider just clicks on buttons to clarify on the record the last checkup conducted, frequency of brushing and toothpaste used, other oral hygiene measures taken and some other information regarding the patient's diet.

The extra-oral examination section collects information on lymph nodes, muscles of mastication, salivary glands and TMJ. It provides a variety of detailed options as clickable dropdown, multi & single select buttons that simplify recording the outcomes of the whole extra-oral examination process.

Following that, a thorough intra-oral and dental examination section includes clickable information related to soft tissues as the tongue, palate, mucosa and gingiva. Teeth charts are available in any notation system you would prefer, in addition to scoring systems as BPE and BEWE. In this section, identify carious teeth, defective restorations, tooth surface loss, crowding or spacing, gingival recession, prostheses, incisive class, and LHS, RHS guidance. All with a click of a button!

Furthermore, radiographs are recorded in their own section. Are bitewings needed? Are periapical x-rays needed? and if so, why?

In the end, the template leaves you with plenty of options to choose from at the Diagnosis section. You can choose as many of the options as you prefer, or add to them in your own words too. This serves as a kickstart to the designated treatment.

As mentioned above, you will find automatic updated information in the Discussion section depending on the buttons you click throughout all portions of the template.

The next section is for Treatment Options, where you are given suggestions of the essential care for the patient such as: root canals, dental implants, extraction, crowns...etc.

You can then enter your own notes in the Treatment Plan section with identifying the follow-up appointments' frequency using NICE dental recall if preferred.

Finally, you can go to appointment scheduling in the Next Visit section by identifying when, where and what is needed for the upcoming visit. There is also a Risk Assessment segment that allows you to rate caries, periodontal, wear, and oral cancer risks by low, moderate and high buttons as options.

If Dental Care is the question, Kiroku is the answer!

Our comprehensive exam template covers all the needed details mandatory in any dental note that puts the dentist at no legal risk at all & helps him/her plan the best care for patients.

Learn more about what goes in a complete dental note and why!

See? Taking dental notes cannot be made easier than this!

‍Sign up on Kiroku, use our stock templates & request your own templates to be made. You will always have the ability to remove any suggestions and edit them as required and the more you do so, the smarter Kiroku gets.

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