Clinical examination and recordkeeping is a complete reference guide to recordkeeping and examination, and is available. Clinical audit report clinical record keeping audit 2012. Fgdp uk members also benefit from a 50% discount on the facultys guidance and standards when they log in to the website and visit the online shop, with a further 15% off when purchasing the complete set of five publications, which also includes selection criteria for dental radiography, clinical examination and recordkeeping. Fgdp selection criteria for dental radiography pdf the fgdp uk provides evidencebased guidance and standards for the whole of the selection criteria for dental radiography is the leading guideline on. Documents include selection criteria for dental radiography guidelines and clinical examination and record keeping amongst others. A new scoring system, the basic erosive wear examination bewe, has been designed to provide a simple tool for use in general practice and to allow comparison to other more discriminative. The faculty of general dental practice has published the second edition of standards in dentistry, for general dental practitioners and their teams which acts as a guide to personal or practicebased quality assessment. This article is the third and final part of a bdj series of practice papers on the subject of clinical examination and related record keeping.
All dental professionals are now able to access dental standards and guidance documents from the fgdp uk. Documents include selection criteria for dental radiography guidelines and clinical examination and record keeping. Clinical examination and recordkeeping fgdp skip to main content. Good record keeping is an integral part of professional practice and the mark of a safe clinician the purpose of this audit is to check what is recorded and implement change where necessary for the benefit of our patients a professional, faithful and accurate clinical record. Dental standards and guidance documents from fgdp uk. August 20, 2018 rds advice sheet on recordkeeping updated august 2018 3 c mcquillan hsc in relation to the retention of patient records, the following applies. Achieving consensus on clinical examination and record keeping in nhs dentistry. It covers all the essential areas of clinical examination and record keeping.
A collaborative audit of clinical recordkeeping standards was performed among. Covering dental records, historytaking, full examination, recall visits, consent, confidentiality, data protection, referrals, electronic records, special situations and more, the third edition has been fully updated and expanded to reflect technological and regulatory developments, and introduces a simple abc system for grading its recommendations. They have an expectation that we will take a history, undertake an examination, provide a diagnosis, offer a range of treatment options and discuss the benefits and risks before embarking on treatment. Dental standards and guidance documents from fgdp uk open. The fgdp uks clinical examination and record keeping. We believe, based on the feedback from our previous candidates, that the mjdf is a truly worthwhile and. Fgdp uk dean, ian mills, examines the benefits of keeping thorough clinical records. Good dental recordkeeping is critical to the practice of dentistry. The history taking process is described in a systematic manner as it is routinely carried out in. Clinical examination and record keeping is a complete reference guide to record keeping.
Over a nine month period, 1,718 patients attended the clinic. To give evidence based assurance that clinical record keeping. Fgdpuk publishes revised standards in dentistry fgdp. Audit on record keeping in the acute hospital setting. The series is taken from the faculty of general dental practice uk fgdp. Over 80% of the patients attending the out of hours ooh clinic had pain associated with a. Plve records audit here is a short selfaudit of patient records for you to complete using this proforma. Record keeping guidance nursing and midwifery council. Records audit as part of the trainer appointment for the year 201617 as part of the trainer appointment process there is a short selfaudit of patient records for you to complete using this proforma. Covering dental records, historytaking, full examination, recall visits, consent, confidentiality, data protection, referrals, electronic records. Documents include selection criteria for dental radiography guidelines and clinical examination and record keeping, among others. Until the end of 2017, fgdp is also offering a 25% anniversary discount on its complete set of guidance publications, which also includes standards in dentistry, clinical examination and record keeping. The introduction explains the importance of good record keeping in the modern dental practice. Fgdp u k standards publication standards in dentistry asserts that a written note should be kept of important features on rad iographs.
Updated fgdpuk guidelines on dental clinical examination. Covering dental records, historytaking, full examination, recall visits, consent, confidentiality, data protection, referrals, electronic records, special situations and. Achieving consensus on clinical examination and record. Nurses, midwives and nursing associates should keep clear and accurate records which are relevant to their practice. To ensure compliance with the relevant national, regional, professional and local clinical record keeping requirements. Patients attend our practices on a regular basis for a routine oral health assessment.
Fgdp uk documents for all dental professionals code. Fgdpuk publishes new guidance on dementiafriendly dentistry. The quality of pharmaceutical products can be affected by a lack of adequate control over. It also summarises almost 70 standards and guidelines publications by the fgdp uk and 30 other organisations relating to the above areas and to. The faculty of general dental practice uk has launched a new edition of its good practice guidelines on clinical examination and recordkeeping gareth kingstone, membership and marketing director at the fgdp. It ensures continuity of care for patients and may help to reduce the likelihood of a complaint. Revised standards in dentistry published by fgdp uk 19 october 2018 the faculty of general dental practice uk has published the second edition of standards in dentistry, aimed at. Clinical examination and recordkeeping is a complete reference guide to recordkeeping and examination, including historytaking, consent, confidentiality, data protection and more. Audit on record keeping in the acute hospital setting page 4 of 71 introduction background to the audit good record keeping is an important aspect of health and social care professionals role. It is important to remember that the book provides guidelines, not requirements, and that national guidelines are.
This publication provides good practice guidelines in clinical examination and record keeping. This is open to both members and nonmembers, through the open standards initiative. Clinical examination and recordkeeping is a complete reference guide to recordkeeping and examination. This article is the second part of a bdj series of. The fgdp uk provides evidencebased guidance and standards for the whole of the selection criteria for dental radiography is the leading guideline on. Fgdp uk publishes revised standards in dentistry news. The faculty of general dental practice fgdp uk has published the second edition of standards in dentistry, its flagship. Fgdp uk publishes its second edition of standards in dentistry the faculty of general dental practice fgdp uk has published the second edition of standards in dentistry, its flagship publication for. This article is the second part of a bdj series of practice papers on the subject of clinical examination and related record keeping. Record keeping is covered by the code there is no specific document on keeping records. The faculty of general dental practice fgdp uk has published the second edition of standards in.
Fgdpuk standards in dentistryfaculty publication 2016. Fgdp uk members also benefit from a 50% discount on the facultys guidance and standards when they log in to the website and visit the online shop, with a further 15% off when purchasing the complete set of five publications, which also includes selection criteria for dental radiography, clinical examination and recordkeeping, antimicrobial prescribing for general dental practitioners and dementiafriendly dentistry. Hadden1 and the fgdpuk clinical examination and recordkeeping working. To ensure this ambition was realised in accordance with the faculty of general dental practice uk fgdp uk guidelines, an additional intention of this work was to engage the profession and relevant stakeholders to establish a consensus on record keeping.
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