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  • Wentworth Avenue
  • Slough
  • Berkshire
  • SL2 2DG

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  • Wentworth Avenue
  • Slough
  • Berkshire
  • SL2 2DG
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Why are good clinical records important?

For effective & efficient orthodontic practice

​Clinical records are used at every consultation and are designed to provide an accurate picture of patient treatment and patient care. Good clinical records are an important means of communication between different health professionals caring for the patient. Records must be contemporaneous, clear, concise and complete. They have most value when they are accurate, up-to-date and accessible when required. ​

For improving standards of patient care

Clinical records are a valuable resource because of the information they contain. Auditing clinical records is an important part of the clinical governance process and records should be written in a way that facilitates this process.

For responding to complaints

Clinical records can provide vital evidence if the standard of orthodontic care is called into question. Many clinical negligence claims are indefensible because records are inaccurate, illegible, too brief or missing. The dentist may have done nothing wrong, but unless the clinical records support this, it can be difficult to defend a claim.

​To facilitate all of the above, I have created some Custom Screens that can be imported into Software of Excellence with simple to follow instructions. I have given an explanation of each one.

Consultation

In my opinion one of the most important parts of the record keeping. It covers everything from verbal consent, patients chief-complaint, incorporates some of Ashley Latter’s communication training, extra-oral exam, intra-oral exam, occlusion, radiographs, treatment summary, problem list, treatment aims, ideal & compromised treatment plan & items you are not planning to correct.

Orthodontic Paperwork

​ This custom screens enables you to record evidence that you have confirmed the patient has completed all of the required documentation, prior to treatment commencement.

Orthodontic Impressions

Once the patient agrees to treatment then photographs and impressions are required, this is where this custom screen comes in.

Also there is a list of what needs to be discussed and what paperwork needs to be completed to achieve written consent.

Six Month Smiles

Six Month Smiles Confidex

This custom screen covers all aspects of the Confidex appointment.

It enables you to document all the information you have discussed with the patient, as well as outlining the details of the treatment.

Six Month Smiles Braces On


This is the perfect Custom Screen for the Braces On visit. It runs through what type of IPR was done and using what method. You can put in what wire size you started with. Along with all the other additional extras like powerchain, elastic thread, biteguards and elastics.

Adjustment Appointments

This Custom Screen runs through all the adjustments that can be carried out at the adjustment appointment.

You can put down if a wire size was changed. If any bracket position was changed or if a bracket was re-cemented.

It runs through what type of IPR was done and using what method. Along with all the other additional extras like powerchain, elastic thread, biteguards and elastics.

Six Month Smiles Braces Off

This covers all of the items that are required in the Braces Off procedure and makes sure that everything is completed in a tick box fashion so that nothing is missed out.

Ceramic/Metal Braces

Bond Up

This is the perfect Custom Screen for the Braces On visit. It runs through what type of IPR was done and using what method, along with what type of brackets were used. You can put in what wire size you started with. Along with all the other additional extras like powerchain, elastic thread, biteguards and elastics.

Adjustment Appointments

This Custom Screen runs through all the adjustments that can be carried out at the adjustment appointment.

You can put down if a wire size was changed. If any bracket position was changed or if a bracket was re-cemented.

It runs through what type of IPR was done and using what method. Along with all the other additional extras like powerchain, elastic thread, biteguards and elastics.

De-bond

This covers all of the items that are required in the de-bond procedure and makes sure that everything is completed in a tick box fashion so that nothing is missed out.

Invisalign

ClinCheck

One of my most favourite Custom Screens which determines going through the ClinCheck with the patient in the order that Invisalign recommend so that nothing is missed. From all views of the animation, Occlusion, IPR, Attachments, Superimposition, Grid movements to length of treatment.

At the end options are given on how the patient would like to proceed.

Aligner Fit

This Custom Screen is used when the first aligner is fitted. You can enter information regarding the attachments and what IPR was done and where.

​Also when you will be seeing the patient again.

Aligner Review

This is used when the patient comes in for adjustment appointments with Invisalign so you can review the aligners.

You can enter information regarding the attachments and what IPR was done and where.

Also when you will be seeing the patient again.

Invisalign Completion

This custom screen documents all required records when completing Invisalign treatment.

You are able to document the final stage of completion including photographs, paperwork and consent.

How to Import a Custom Screen

Please use this downloadable guide on how to import a custom screen, once you receive yours.

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Moonlight Dental Surgery. Wentworth Avenue, Slough Berkshire SL2 2DG

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