Interpreting dental notes and expert reports
Produced in partnership with Mike Hill of Trinity Chambers

The following PI & Clinical Negligence practice note produced in partnership with Mike Hill of Trinity Chambers provides comprehensive and up to date legal information covering:

  • Interpreting dental notes and expert reports
  • Dental notes
  • Paper records
  • Computerised records
  • Radiographs
  • The NHS Business Services Authority
  • Tooth nomenclature
  • Interpretation of radiographs
  • Dental charts
  • Expert reports

Interpreting dental notes and expert reports

Dental notes

A common difficulty for lawyers dealing with dental negligence claims is the nomenclature in the notes. The format of notes has changed over the years and continues to evolve.

Paper records

Until approximately the year 2000, very few practices had computerised records. The vast majority wrote clinical records on NHS-derived standardised buff cards (the FP25). Predictably, handwriting was poor and the nomenclature made things even more difficult to decipher. The buff colour of the notes makes photocopying difficult. If the notes are hard to read, practitioners should return to practices to ask for better copies, copied on a colour copying machine if necessary.

Missing cards were common in practice and there often existed a duplicate set of notes. Many practices recorded the card number at the top of the FP25 and continuity should be checked. Occasionally, it is simply not possible for either solicitor or expert to be able to determine what the notes say. In those circumstances it is appropriate for a claimant solicitor to ask the indemnifier to ask the dentist what the notes say.

Computerised records

From 2000 onwards, computerised records became far more widely used. Many practices used both systems while dentists and staff adjusted. Often, dentists would handwrite the records and the reception staff would use the computerised system to invoice and record appointments and NHS treatment codes

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