There's no information in the NHS Dental Regulations about this.
The only advice we can offer is based on recommendations from:
- the Department of Health and Social Care (DHSC)
- the College of General Dentistry
- various professional indemnity organisations
A clinician must always take an initial full medical history (MH) in discussion with the patient to be sure the treatment proposed is appropriate and acceptable to the patient, and that care is delivered safely.
This MH form should be signed and dated by the patient or their representative and the clinician. This is to evidence that the information was provided.
General Dental Practice's with computerised records are advised to keep a signed and dated hard copy base-line MH questionnaire that can be scanned into the system. Alternative options are that the patient and clinician provide electronic signatures, if the system allows this, and that the system allows the clinician to demonstrate that the MH has been recorded, verified and clarified with the patient.
The system should hold an audit trail confirming entries have been made on the relevant page at the appropriate date. An entry can also be written in the notes to confirm the clinician has noted the details and where necessary clarified with the patient.
MH must be confirmed, dated and initialled by the patient and the dentist at the start of each subsequent Course of Treatment (CoT).
The MH form can be checked and initialled on behalf of the dentist by a suitably qualified dental care professional (DCP), who should inform the dentist of any change and must be checked at each appointment where invasive treatment is to be carried out.
Care must be taken in updating MH in the presence of third parties including family members. Confidential information must not disclosed without the patient's consent.
If you do not agree with this information or need further clarification, you must seek a definitive opinion from your professional indemnity organisation.