We have developed standard operating protocols (SOPs) to help streamline record keeping practices for oral healthcare teams and encourage a more proportionate and concise way of recording clinical notes.

These include example SOPs for:

• routine, non-surgical dental extraction
• orthograde (first time) root canal treatment
• dental crown or indirect onlay preparation and fit
• an anterior composite restoration

We have also published examples of clinical records with or without standard operating protocols.

Why these standard operating protocols are important

We recognise that clinical teams will repeat common steps whilst treating patients. Writing these steps out in full each time in the clinical notes not only places an additional time constraint on the clinician but also makes the details unique to the appointment contained within the notes harder to find. Therefore, the usage of SOPs is proposed as a way of streamlining record keeping.

The example SOPs are not designed to be exhaustive. Each clinical team should interpret and adapt their protocols as required for their clinical practice. Clinical teams should ensure that their record keeping practices are appropriate to each patient interaction.

It is expected that each organisation will have an agreed bank of SOPs that cover frequent clinical protocols. These will be agreed by the organisation and reflect the clinical way of working. One SOP will not always cover the assessment or care delivery undertaken in an entire appointment, instead, multiple SOPs may need to be referenced in the notes for that appointment.

The SOPs should not constrain clinical freedom. There is valid variation between clinicians and clinical teams in terms of operating protocols, related to preferred clinical approaches and use of dental materials.

The SOPs will also not cover every appointment specific detail. Therefore, a small amount of additional detail in the clinical records will still be required. For example, the amount of local anaesthetic used will need to be added to the patient record, as this will vary.

SOPs used within clinical practice should have regular review dates or be reviewed earlier if there is a significant change, to ensure that the content reflects current ways of working.

Contact us

If you have any questions or feedback on the SOPs, please email england.cdoexecutive@nhs.net