The health record is a record of services rendered. It provides justification for all treatment provided and information upon which to base subsequent care.

If a patient is seen by more than one health professional, the health record aids in continuity of care. If the clinic provides services other than oral health services (e.g., medical services, counseling, social services), the same health record should be used throughout the clinic.

There are no universal standards for the content of a health record. Following are suggestions about what to keep in a health record, and what should not be kept in a health record.

Information to Be Kept in a Health Record

• Medical history, including updates to the history at each visit
• Present complaints
• Oral examination
• Written, sequential treatment plan
• Allergies
• Medications
• Clinical findings
• Laboratory and radiology reports
• Recommended follow-up
• Written informed consent (For more information on informed consent, see module 5, Informed Consent.)
• Other information considered to be of clinical value

Information That Should Not Be Kept in a Health Record

• Copies of prescriptions. Anyone who obtains a copy of prescription slips can forge prescriptions. Do not include medication type, dose, amount, directions for use, or number of refills. Keep such information in a separate file.
• Documentation regarding any discussion with an attorney or liability insurance carrier about a potential malpractice claim. Records are obtainable by the patient and the patient's attorney. All information in the health record may be considered discoverable and not privileged. Keep such documentation in a separate file.
• Critical or subjective comments about the patient. The health record should include only relevant, factual comments about the patient's condition and treatment. Subjective, negative, or irrelevant comments may reflect poorly on the health professional's professionalism. When documenting the dentist-patient relationship, use direct quotes whenever possible.
• The patient's financial information. The cost of care and the patient's payment history can influence how care is perceived. Financial records should be kept separate from the health record.
  
  

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