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Principle One

Put patient's interests first

 

Principle Two

Communicate effectively with patients

 

Principle Three

Obtain valid consent

 

Principle Four

Maintain and protect patients' information

 

Principle Five

Have a clear and effective complaints procedure

 

Principle Six

Work with colleagues in a way that is in patients' best interests

 

Principle Seven

Maintain, develop and work within your professional knowledge and skills

 

Principle Eight

Raise concerns if patients are at risk

 

Principle Nine

Make sure your personal behaviour maintains patients' confidence in you and the dental profession

 

Principle Four

Maintain and protect patients' information

 

Learning Material Case Study

Record Keeping

Mrs Wilson is a dentist. Mr Smith, the patient, contacted the GDC stating that Mrs Wilson had extracted two of his teeth without any local anaesthetic.

Mr Smith said that one of his teeth was loose and so would have been fine to extract without anaesthetic but the other one was still firmly in place and the extraction caused him a great deal of pain.

The fitness to practise caseworker considered that Mrs Wilson may have breached the following section from Standards for the Dental Team:

  • 1.2.3 You must treat patients with kindness and compassion and manage their dental pain appropriately.

The Investigating Committee considered the case. However, in her response to the allegations, Mrs Wilson stated that she had given Mr Smith local anaesthesia before carrying out the extractions.

She provided the Investigating Committee with a copy of Mr Smith’s records. The records were computerised so it was clear what date the records were made. The records were very detailed and included summaries of the discussions Mrs Wilson had with Mr Smith before the treatment and the batch number of the cartridge of local anaesthetic which she used. The Investigating Committee decided to take no further action.

​In this case, having complete and accurate patient records provided sufficient evidence to the Investigating Committee that Mrs Wilson had adhered to the standards and guidance set out in Standards for the Dental Team.

It is vital that you keep complete and accurate patient records. With many of our fitness to practise cases our committees are often faced with two very different recollections of the same event and the records are often the only evidence that can be produced in defence of allegations made against registrants. Record as much information as possible, include the name of the registrant providing the treatment and if you have to make amendments to records, make sure that those changes are clearly marked and dated.