Mehta Shamir B, Rattan Raj, D Cruz Len
Lead Clinical Adviser, Fitness to Practise, Regulation Directorate, General Dental Council, UK; Programme Director MSc in Aesthetic Dentistry, King´s College London, Faculty of Dentistry, Oral and Craniofacial Sciences, Guy´s Campus, London, UK.
Dental Director, Dental Protection Ltd, UK.
Br Dent J. 2025 Sep;239(5):343-349. doi: 10.1038/s41415-025-8604-8. Epub 2025 Sep 12.
This article provides an overview of the composition and purpose of record-keeping in dental practice and in the context of a General Dental Council (GDC) fitness to practise (FtP) investigation. It includes an overview of the GDC's FtP process. The importance of making appropriate patient records from a dento-legal perspective is also highlighted, together with changing trends in record-keeping in the United Kingdom over the past 50 years and factors that have contributed to 'note bloat' - a term that describes unnecessarily lengthy (at times, superfluous) records. It calls for a shift in current practice and explores alternative options for record-keeping in a more concise way and discusses how this may be achieved.
本文概述了牙科诊疗中记录保存的构成和目的,以及在英国牙科总会(GDC)执业适用性(FtP)调查背景下的情况。其中包括GDC的FtP程序概述。还强调了从牙医学法律角度进行适当患者记录的重要性,以及过去50年英国记录保存的变化趋势和导致“记录冗长”(该术语描述了不必要的冗长记录,有时是多余的)的因素。文章呼吁改变当前的做法,探索以更简洁的方式进行记录保存的替代方案,并讨论如何实现这一点。