Communication and Record Keeping

Use a plain language and easy to understand terms

Adjust communication style accordingly to patient ability to understand dental ‘words’

Stay in touch with carers and auxilliary staff

An essential part of a record keeping is an individual assessment of patient’s general health

Always use a non-judgemental approach

Practical terms which can be used in patient’s record:

  • ‘cooperative’, ‘non-cooperative’, ‘partially cooperative’, ‘initially cooperative’, ‘seems to be cooperative’
  • ‘dental phobic’, ‘low/moderate/high level of dental anxiety’,’ fairly/mildly/highly anxious’, ‘extremelly nervous and worried’
  • ‘calm’, ‘agitated’, ‘fidgitive’, ‘restless’, ‘noisy/loud’,
  • ‘generally healthy’, ‘fit&healthy’, ‘multiple health problems’
  • ‘physically disable’, ‘mental health issue’, ‘complex health problems’, ‘multi-disability’, ‘
  • ‘would not tolerate…’, ,cannot cope with….’, ‘unable to sit steady’, ‘unvoluntary movements’
  • ‘impaired vision’, ‘deaf’, ‘acuired/hereditary impairement’
  • ‘lack of understanding and retaining information’, ‘seems to be aware of …’, ‘able to understand but unable to communicate the information given’
  • ‘normal communication’, ‘communicates well…’, ‘communication maintained’, ‘unable to communicate…’, ‘comunication compromised’
  • ‘wheelchair bound’, ‘bed bound’, ‘uses walking sticks/aids’, ‘uses electric scooter’
  • ‘only non verbal communication possible’
  • ‘lack of mental capacity to consent’, ‘unable to consent’
  • ‘informed consent not possible’, ‘valid consent gained for tx plan’
  • ‘capacity assessment required’, ‘to consider capacity assessment’