The British Dental Association has backed moves towards a more common sense model of record keeping in practices.
The professional body believe NHS England’s new standard operating procedures (SOPs) may support clinicians to adopt a more proportionate and efficient system of recording clinical treatments.
The new model recognises that much of the clinical treatment provided in general dental practice have common steps repeated and recording each of those steps at each appointment takes time, which can make important details unique to that appointment harder to find when other clinicians treating the patient need to review them.
The four SOPs developed are not designed to be exhaustive and each clinical team would create their own protocols suited to their style of working. The intention is that each practice will have an agreed bank of SOPs that cover frequent clinical protocols. There is no intention to standardise clinical practise across the country or to constrain clinical freedom.
This approach builds on proposals originally set out in the British Dental Journal in 2025, which specifically proposed the use of SOPs to reduce unnecessary repetition in patient notes. The article was authored by Dental Protection’s Prof Raj Rattan alongside Dr Len D’Cruz, Head of BDA Indemnity and Dr Shamir Mehta of the GDC.
Len D’Cruz, Head of BDA Indemnity, said:
“A common complaint from dentists is the sheer amount of time it takes to write up their clinical records after an appointment.
“The GDC requires these to be written contemporaneously, but many clinicians struggle to do this while working against the clock.
“Templates have become common, but these can become the source of problems when they come pre-populated and don’t reflect what actually happened in an appointment.
“Copious notes do not necessarily mean more accurate notes, and a propensity to repetitiously detail treatment in the mistaken belief that it will protect dentists has led us to where we are.
“The use of SOPs offers a chance to take the edge off these problems across both NHS and private practice. They can also act a checklist for clinicians which will help provide consistent and quality care to patients.
“As a defence organization, BDA Indemnity encourages clinicians to look at these SOPS and think about how they can be put to work in their own practices.”
NHS England has published four examples of SOPs covering extractions, root canal treatment, crown and onlay procedures and anterior composite restorations, encouraging practices to build more for their own individual styles of practicing.
