Principle Four
Maintain and protect patients’ information
Patients expect:
- Their records to be up to date, complete, clear, accurate and legible
- Their personal details to be kept confidential
- To be able to access their dental records
- Their records to be stored securely
Standards & their guidance
Guidance
- 4.1.1 You must make and keep complete and accurate patient records, including an up-to-date medical history, each time that you treat patients. Radiographs, consent forms, photographs, models, audio or visual recordings of consultations, laboratory prescriptions, statements of conformity and referral letters all form part of patients records where they are available.
- 4.1.2 You should record as much detail as possible about the discussions you have with your patients, including evidence that valid consent has been obtained. You should also include details of any particular patient’s treatment needs where appropriate.
- 4.1.3 You must understand and meet your responsibilities in relation to patient information in line with current legislation. You must follow appropriate national advice on retaining, storing and disposing of patient records.
- 4.1.4 You must ensure that all documentation that records your work, including patient records, is clear, legible, accurate, and can be readily understood by others. You must also record the name or initials of the treating clinician.
- 4.1.5 If you need to make any amendments to a patient’s records you must make sure that the changes are clearly marked up and dated.
- 4.1.6 If you refer a patient to another dental professional or other health professional, you must make an accurate record of this referral in the patient’s notes and include a written prescription when necessary.
Guidance
- 4.2.1 Confidentiality is central to the relationship and trust between you and your patients. You must keep patient information confidential. This applies to all the information about patients that you have learnt in your professional role including personal details, medical history, what treatment they are having and how much it costs.
- 4.2.2 You must ensure that non-registered members of the dental team are aware of the importance of confidentiality and that they keep patient information confidential at all times.
- 4.2.3 You must not post any information or comments about patients on social networking or blogging sites. If you use professional social media to discuss anonymised cases for the purpose of discussing best practice you must be careful that the patient or patients cannot be identified. See our website for further guidance on social networking.
- 4.2.4 You must not talk about patients or their treatment in places where you can be overheard by people who should not have access to the information you are discussing.
- 4.2.5 You must explain to patients the circumstances in which you may need to share information with others involved in their healthcare. This includes making sure that they understand:
- what information you will be releasing;
- why you will be releasing it; and
- the likely consequences of you releasing the information.
You must give your patients the opportunity to withhold their permission to share information in this way unless exceptional circumstances apply. You must record in your patient’s notes whether or not they gave their permission.
- 4.2.6 If a patient allows you to share information about them, you should ensure that anyone you share it with understands that it is confidential.
- 4.2.7 If other people ask you to provide information about patients (for example, for teaching or research), or if you want to use patient information such as photographs for any reason, you must:
- explain to patients how the information or images will be used;
- check that patients understand what they are agreeing to;
- obtain and record the patients’ consent to their use;
- only release or use the minimum information necessary for the purpose; and
- explain to the patients that they can withdraw their permission at any time.
If it is not necessary for patients to be identified, you must make sure they remain anonymous in any information you release.
- 4.2.8 You must keep patient information confidential even after patients die.
- 4.2.9 The duty to keep information confidential also covers recordings or images of patients such as photographs, videos or audio recordings, both originals and copies, including those made on a mobile phone. You must not make any recordings or images without the patient’s permission.
Guidance
- 4.3.1 In exceptional circumstances, you may be justified in releasing confidential patient information without their consent if doing so is in the best interests of the public or the patient. This could happen if a patient puts their own safety or that of others at serious risk, or if information about a patient could be important in preventing or detecting a serious crime. If you believe that revealing information about a patient is in the best interests of the public or the patient you should first try to get the patient’s permission to release the information. You should do everything you can to encourage the patient to either release the information themselves or to give you permission to do so. You must document the efforts you have made to obtain consent in the patient’s notes.
- 4.3.2 If obtaining consent from a patient to the release of their information in the public interest is not practical or appropriate, or if the patient will not give their permission, you should get advice from your defence organisation or professional association before you release the information.
- 4.3.3 If you have information that a patient is or could be at risk of significant harm, or you suspect that a patient is a victim of abuse, you must inform the appropriate social care agencies or the police. See our website for further guidance.
- 4.3.4 You can be ordered by a court, or you can be under a statutory duty, to release information about a patient without their permission. If this happens, you should only release the minimum amount of information necessary to comply with the court order or statutory duty.
- 4.3.5 In any circumstance where you decide to release confidential information, you must document your reasons and be prepared to explain and justify your decision and actions.
Guidance
- 4.4.1 Although patients do not own their dental records, they have the right to access them under Data Protection legislation. If patients ask for access to their records, you must arrange for this promptly, in accordance with the law.
- 4.4.2 In some circumstances you can charge patients a fee for accessing their records. The maximum you can charge depends on whether the records are paper copies or held electronically. You should check the latest guidance issued by your national Information Commissioner’s Office.
Guidance
- 4.5.1 You must make sure that patients’ information is not revealed accidentally and that no-one has unauthorised access to it by storing it securely at all times. You must not leave records where they can be seen by other patients, unauthorised staff or members or the public.
- 4.5.2 If you are sending confidential information, you should use a secure method. If you are sending or storing confidential information electronically, you should ensure that it is encrypted.
- 4.5.3 If clinical records are computerised, you should make back-up copies of clinical records, radiographs and other images.
Learning Material & case studies
Case Studies for principle 4
Frequently Asked Questions