Why record keeping matters

Infection prevention and control is fundamental to all healthcare sectors, and in England all registered providers of health and social care must meet the Code of Practice on the prevention and control of infections, a document that sets out the code of practice and control of infections under the Health and Social Care Act 2008[i].

The Code states: “Effective prevention and control of infection must be part of everyday practice and be applied consistently by everyone. Good management and organisational processes are crucial to make sure that high standards of infection prevention (including cleanliness) are developed and maintained.[ii]”

Record keeping is not just a box ticking exercise, it is an essential part of compliance with the legal and regulatory requirements of infection control and promotes good practice and wider knowledge of the subject. A clear and concise record keeping process ensures there are no shortfalls in infection control routines, and streamlines other aspects of infection control to provide a full audit trail of compliance to keep patients, staff and the practice as a whole, protected at all times.

Responsibility

UK guidance states that all dental practices must have a nominated lead member of staff responsible for infection control and decontamination, a role often fulfilled by the practice manager or lead dental nurse. This role includes ensuring all staff understand and follow the practice’s infection control policy and receive appropriate training. The responsible person must also make sure that training records are maintained, and that processes and policies are evidenced and up to date.

The decontamination lead can also nominate or adopt the role of designated person. It is the designated person’s responsibility to ‘act as the interface between the practice and support services supplied externally, including service, maintenance and testing’[iii]. This task covers all testing and validation records and ensuring decontamination equipment is serviced/validated – and in the case of steam sterilisers, undergo a pressure vessel inspection (PVI check) – in accordance with manufacturers’ guidelines.

The CQC (Care Quality Commission) in England states that all testing and validation documentation should be retained by a practice for a minimum of two years. However, it is considered good practice to keep these records for the same minimum retention period as patient records, as advised by regional health authorities in case a complaint or litigation should arise.

In England and Wales, for adult patients the NHS currently recommends a retention period of a minimum of 15 years, while the Scottish government advises a minimum of 10 years from when the patient last attended[iv]. In Northern Ireland there is guidance on record retention from the Department of Health and contained within the Regulation and Improvement Authority (Independent Health Care) (Fees and Frequency of Inspections (Amendment) Regulations (Northern Ireland) 2011[v].

Accountability

Dental care professionals (DCPs) are accountable practitioners who have a legal obligation to ensure they discharge the duties imposed on them by law, including preventing the spread of infection[vi]. Where a DCP fails to meet the standards imposed on them they will have to answer to a range of higher bodies that have legal authority over them[vii].

A dentist was struck off by the General Dental Council’s (GDC) Professional Conduct Committee (PCC) (GDC, 2017) for multiple failings involving wide-ranging cross infection control, standard of care to patients and record keeping. As well as not routinely changing gloves and masks between patients and failing to ensure dental instruments and equipment were adequately cleaned, the PCC also found it proven that 12 patients were affected by the dentist’s inadequate standard of care and record keeping[viii].

Record keeping

The guidelines on decontamination procedures vary slightly across the UK as indicated in Wales WHTM 01-05, Northern Ireland HTN 01-05 and Scotland SDCEP and SHTM 01-05 (updated April 2024). For example, in Scotland and Northern Ireland, a separate decontamination room and washer disinfector are mandatory, while in England and Wales these two items are required if a practice is to attain ‘best practice’ status.

Each piece of decontamination equipment, including autoclaves, ultrasonic cleaners and washer disinfectors, require a specific document that should detail a complete history of each item and which can be completed according to the test being carried out on a daily, weekly, quarterly or annual basis.

Practices have various options for record keeping and these include:

• Templates provided in guidance documents such as HTM 01-05 and WHTM 01-05.
• NHSScotland log books for washer disinfectors, ultrasonic cleaners and sterilisers located on the NSS website for use in conjunction with relevant SHTM Guidance Publications[ix].
• A manufacturer’s log book specific to each machine.
• A supplier’s log book.

Whichever method is used, the document should be clearly laid out and provide an easy prompt for decon leads and those responsible to complete the necessary details. It is also important to record quarterly and annual audits carried out by 3rd party engineers and to maintain a faults and repair record.

The need for compliance

HTM 01-05 emphasises the need for validation, testing, maintenance and servicing as recommended by the manufacturer/supplier and that all records of these procedures should be up-to-date and be retained for audit/inspection purposes at any time. Section 11.3 states: “Failure to perform these tasks or retain evidence of their performance may indicate non-compliance of the decontamination process”.

The CQC in England states that in order to meet Essential Quality Requirements, periodic tests should be carried out in accordance with manufacturers’ instructions or as set out in HTM 01-05 for sterilisers, ultrasonic baths and washer-disinfectors. Documentation relating to these tests should be “available for inspection” and it is advised to “keep hard copy records with the steriliser log book, either within the log book or in a separate folder”[x].

In Scotland, the Scottish Health Technical Memorandum (SHTM) 01-05 provides practical guidance on validating and testing decontamination equipment. It also covers the equipment used within the Local Decontamination Unit (LDU) and outlines the exact testing/validation and maintenance procedures that are required to be adopted[xi].

Additional record keeping

Record keeping is not just confined to patient records and decontamination equipment. Other examples include:

• A record of CPD hours as an important part of maintaining GDC registration.
• Staff immunisation and screening records to ensure members of the dental team are protected against diseases such as tetanus, polio, diphtheria, measles, mumps and rubella (MMR) and hepatitis B.
• Hand hygiene policy – a useful example can be found on page 76 of HTM 01-05[xii].
• Water quality testing, including Legionella risk assessment and dental unit water lines (DUWLs).
• Handpiece decontamination procedures.
• Individual staff training records.

Record keeping is a key task for dental teams and the standard of record keeping ultimately reflects on the standard of professional practice. Guidance around record keeping is always subject to change, so it is important to keep up to date with the latest legislation and relevant local guidelines.

By using the correct methods designed to enhance and optimise record keeping and traceability, practices can remain compliant and demonstrate a strong commitment to providing the highest standard of care to patients.