The Importance of Dental Decontamination Record Keeping

Accurate record keeping is an essential part of running a modern dental practice and is necessary in the provision of high-quality, safe and effective patient care. It creates a physical audit that enables your practice to demonstrate compliance with legal and regulatory requirements and provides a permanent record of levels of care that might prove useful in the event of patient complaints or litigation.

Why is Decontamination Record Keeping Essential?

Documentation provides evidence of completed and successful decontamination processes. 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 and the practice always protected.

Each piece of decontamination equipment requires a specific document which should detail a complete history of each item which can be completed according to the test being carried out on a daily, weekly, quarterly or annual basis.

Who in the Dental Practice is Responsible for Keeping Records?

HTM 01-05 and 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 of Decontamination Lead includes ensuring all systems, procedures and records for infection control and decontamination are in place, that staff members are correctly trained and competent, and that all essential processes and policies are evidenced and up to date.

The Decontamination Lead can also nominate or adopt the role of a 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’. This includes maintaining all testing and validation records for decontamination equipment and ensuring this equipment is serviced/validated, and in the case of steam sterilisers, undergo a pressure vessel inspection (PVI check) in accordance with manufacturers’ guidance.

Does Dental Equipment Testing and Servicing Need Recording?

Absolutely. 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 this 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”.

The CQC 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 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 minimum of 15 years while the Scottish government advises a minimum of 10 years from when the patient last attended.