The Dental Board of Australia (DBA) retired the former Guidelines on Dental Records on October 1, 2020.
What is the current standard and how can I be sure my records meet it?
The Advisory Services team has compiled the following list of resources for practitioners who are interested in evaluating and/or improving their record keeping practices. Please keep a record of all activities you undertake in this area and include these in your CPD logbook. Time spent attending courses, reading journal articles on this topic and in auditing your records is classified as scientific and will attract one CPD hour per hour of engagement.
Rules and regulations:
Dental Board of Australia
The Dental Board of Australia (DBA) describes the Australian standard for dental record keeping in the Code of Conduct. Please refer particularly to section 8.3 on Health Records which describes the guiding principles which must be applied (the Standard).
The Code of Conduct is supported by the following key explanatory documents:
- Dental Board of Australia: Factsheet – Maintaining your patient health records
- Dental Board of Australia: Self-reflective tool – Good record keeping
Australian Privacy Laws
The collection, use and disposal of personal information (dental records) is governed by the Australian Privacy Principles (the APP’s) under the Privacy Act 1988 (Cth). The APP’s are described in ADA Inc Policy 5.17 with additional detail available on the Office of the Australian Information Commissioner (OAIC) website. To access a comprehensive suite of information, templates and privacy resources, please click on the link to ADA NSW’s Privacy Kit located in the table below.
Continuing professional development:
Face-to-face courses
To locate a course proceed to the ADA NSW CPD website and perform a search using the search term word “records”. ADA NSW regularly runs a course titled Dental Records, Consent and Complaints Management. If you are interested in attending but the course is booked out please join the waiting list.
Other reputable courses are run by Sydney University, Faculty of Dentistry and the Royal College of Dental Surgeons.
Online interactive dental records course
ADA NSW runs an Online Dental Records and Consent course. It takes an hour or two to complete and a certificate of completion is provided. You will need to log in using your username (ADA NSW member number) and password. A course fee of $330 is applicable.
Online lectures, videos and audio content (free for ADA members)
The ADA Inc CPD Portal offers a wealth of material including webinars, lectures, videos and audio recordings. As well as learning about dental record keeping, you will also find content relating to diagnosis, treatment planning and clinical treatment which may be of interest.
Default Login details:
Username = ADA Inc. Member Number
Password = ADA Inc. Member Number followed by initials in lower case
In particular, we recommend Dr Milford’s free course ‘Record Keeping: Essential knowledge to avoid pitfalls‘ and Part 2. (References the now-retired DBA Guidelines on Dental Recordkeeping. However, the expectations in the new Reflective Tool are substantially the same).
Journals, magazines and professional publications
The ADA NSW Library is the repository of numerous Australian and International journals, magazines and professional publications. To conduct a literature search, you could either visit the library personally, search the database online or phone (02) 8436 9900 to request guidance and assistance.
Journal articles can also be accessed on the ADA Inc website via the National Digital Library.
Self-assessment/audit of dental records:
Performing a self-assessment or audit of your dental records
The Dental Council of NSW (DC) commonly assess practitioner records using an audit checklist. Information on the Council’s inspection/audit process is available on the Dental Council of NSW’s website.
You may wish to perform an audit of your own records to ensure you are meeting the standard required. There are a number of excellent dental record audit tools available to assist you – please access these via the table below.
Advisory Services Information Kit:
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Privacy regulations |
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Dental records audit |
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Dental records information |
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Medical history information |
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Templates |
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NSQHS Informed Consent in Health Care Factsheet for Clinicians |
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Item No 013 Limited Consultation Where Patient Attends in Pain Aide Memoire |
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More information on: |
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I’ve Received a Request for Records: What Should I Do? Parts 1 and 2 |
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Additional resources:
More resources are available under Members Centre/Advisory Services.
Should you have any questions, please do not hesitate to email or call the Advisory Services team on (02) 8436 9944.
