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Dental Records and X-Rays - Legal and Regulatory Obligations

DATE: 24.06.2011

 

Contemporaneous dental record keeping can not only reduce the risk of subsequent legal claims but may also assist in defending such claims should they arise. Furthermore, the keeping of adequate records has in recent years become the subject of legislative control, particularly in the context of patient x-rays.

Dental practitioners are under an ethical duty to maintain adequate and accurate records of all matters relating to their treatment of patients, and to retain these in a secure location, for an adequate time period (at least 10 – 12 years).

Records should:

(a) Be clear and legible, and should contain the date and author in an identifiable fashion.

(b) Contain sufficient content to be informative and ensure both positive and negative findings, as well as recording information given to patients and the decisions made.

(c) Detail treatment decisions in a manner sufficient to allow an independent observer to rationalise the decision and to justify the course of action taken.

(d) Detail the fact that risks and benefits have been adequately explained to a patient when consenting for dental treatment.

In the context of dental x-rays, a number of statutory controls have been introduced in recent years(1). Pursuant to Irish legislation(2) a dental practitioner is obliged to:

(a) State in writing his/her reason for requesting a radiograph, and

(b) Satisfy himself/herself that the procedure can be clinically justified.

This can be contrasted with the situation in England where dental practitioners are required not only to keep written notes about the justification for giving the x-ray but also to keep a written record of the findings of such x-rays and maintain detailed notes about the procedure itself(3). Although the Irish legislation does not stretch this far, best practice would suggest this approach be followed here, to avoid litigation and ensure the best standards of patient safety.

1. See the following: The Radiological Protection Act, 1991; The Radiological Protection Act, 1991 (Ionising Radiation) Order, 2000 (S.I. No. 125 of 2000) implementing EC Directive 96/29/Euratom (Basic Safety Standards Directive), and EC Directive 90/641/Euratom (Outside Workers Directive); EC (Medical Ionising Radiation) Regulations, 2002 (S.I. No. 478 of 2002), as amended, implementing EC Directive 97/43; The Safety, Health and Welfare at Work Act 2005 (No. 10 of 2005). See also the Radiological Protection Institute of Ireland’s “Code of Practice for Radiological Protection in Dentistry”. 2. European Communities (Medical Ionising Radiation Protection) Regulations (SI 478 of 2002), as amended by the European Communities (Medical Ionising Radiation Protection) (Amendment) Regulations (SI 303 of 2007) dated 4 March 2010. 3. See The Ionising Radiation (Medical Exposure) Regulations (IRMER) 2000 (SI No 1059 of 2000)
 
 

 

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