LAUSR

Introduction Members of the dental profession in the UK are legally required to create and maintain patient records. In 2016, the Faculty of General Dental Practice (UK) published the third edition of its good practice guidelines on clinical examination and record keeping. Aim To identify a core set of items which should be recorded in three clinical situations (new patient appointment; recall appointment; emergency appointment) in primary dental care. Design Four-stage Delphi methodology. Methods Stage one: a comprehensive list of items taken from the FGDP guidance were reviewed by an expert group for relevance and clarity in relation to three scenarios (new patient appointment, recall appointment; emergency appointment). The panel was also asked to identify their perceptions of any omissions or redundancies. Stage two: following feedback of the results, the expert group again reviewed the full item list, with the addition of any items identified in stage one. Consensus was defined as 75% or more of the panel agreeing on the score for an item. Stage three: online survey of dental practitioners (N = 2,840) asking them to rate the relevance of the item pool for the same clinical scenarios. Stage four: a second expert group was formed and asked to rate the feasibility of implementing each item as 'essential' to record in primary dental care. The final list of items rated as 'essential' and feasible comprises: 21 items for new patient appointments; 17 items for recall appointments; ten items for emergency appointments. Results A high degree of consensus was found between the expert group and dental practitioners regarding those items viewed as 'essential' to be recorded across the three appointment types. Conclusions A core set of items are identified as 'essential' and feasible to be recorded for three different types of dental consultation in primary care: new patient appointment, recall and emergency appointment.