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Dental Nurse Charting: Recording Keeping in Dental Practice

Used in every dental practice up and down the country, nurses use dental charts to make note of teeth, identifying work that needs to be completed and to monitor what has already been done during a procedure. Although systems may vary, nurses keep a diagrammatic map that resembles the surface of patient teeth. This chart can be used to assist during surgery and enables them to keep an accurate record of the patient’s dental history.
Being able to chart is a key skill that all nurses are trained to do which can be an intimidating task at first. Despite this, charting does not have to be difficult and can be easily learnt. It is a crucial part of any procedure and nurses play an integral part in this.

Purpose

Not only does charting record the number of teeth or procedures that are being carried out, nurses also make note of any areas of tooth decay, the depth of gum pockets, dental movement and observe evidence of bleeding. The chart helps practice staff to build a full record that is easy to understand and quick to access in all future appointments.

Notation

Although patient notation can differ depending on the practice, the systems are normally the same. Whether it’s the Zsigmondy-Palmer notation or forensic notation, both methods use grids that enable staff to visualise and keep track of work as it is performed.
While chart-making, nurses should be able to identify the correct surfaces of teeth, including their names and symbols that are relevant to the procedure being carried out. Since practices are legally required to maintain accurate patient notes, nurses must be confident in their definition recall and have the ability to work accurately under pressure.

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Forensics

Charting is also a key method used in forensic work to identify individuals during post-mortems particularly when they have received severe injuries and cannot be identified in any other way. Nurses interested in a career in forensics will utilise dental charting to identify victims and help the police and legal teams with their investigations. There is a great deal of responsibility here to record and analyse accurately as the evidence generated can be used in court cases.
Charting is essential, not only for practices to maintain accurate patient records, but to help dentists while they perform procedures. Dentists value the support of their dental nurses to maintain these charts as it is essential that the surgery can produce accurate records. Dental charting is taught as part of the dental nursing diploma and those who take part must pass assessments in order to qualify.
Patient’s have a right to access their data on request and should there be any question about the procedure or treatment provided, the practice can refer to these charts to inform their response. Ultimately, it’s essential that all practices establish a stringent procedure to accurately record evidence. Patients will want the reassurance that their dental teams are organised and transparent so that they can be confident that they are receiving the best care possible.

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