Dental record keeping audit template
Pick ten notes from the last month. Score each line yes or no. The point is to find the line you keep skipping, not to get a perfect score.
Template
Note date and clinician Patient identifier removed before the audit History updated, or "no change" written Complaint in the patient's words Findings, not just the treatment A diagnosis Options, and which one was chosen Consent, including a risk What was done Drugs or anaesthetic, if any Next step Could another dentist treat the patient from this note alone?
A filled-in example
Ten notes, March 2026.
History was missing on 4. Diagnosis was missing on 6. Consent was a word, "consented", on 7, with no risk named.
The line we skip is the diagnosis. We write the filling and not why.
Next month: the diagnosis goes on its own line. Audit the same ten questions again.
Let Dentascribe fill this in from your appointment audio.
