38.3 Referrals, Records and Communication with the Team
Key Takeaways
- The specific clinical question being asked is the most important element of a referral letter, and please see and treat is not a referral question.
- Radiographs already taken must be shared with the referral so that repeat exposure is avoided, consistent with IR(ME)R justification.
- Dental records are special category personal data under UK GDPR, requiring a lawful basis and an additional processing condition.
- A data breach likely to result in risk to individuals must be notified to the Information Commissioner's Office within 72 hours.
- Under the NHS Records Management Code of Practice adult dental care records are retained for 15 years and children's records until the patient's 25th birthday.
Written and Electronic Communication
Preparing for Practice outcome 5.2 requires the use of "appropriate methods to provide accurate, clear and comprehensive information when referring patients", and outcome 5.5 requires registrants to "recognise and act within the principles of information governance".
Writing a Referral
A referral letter is a clinical handover, and a poor one delays or misdirects care. It should contain:
| Element | Why it matters |
|---|---|
| Patient identifiers — full name, date of birth, address, NHS number where available | Prevents misidentification |
| Referrer details including GDC number and practice contact | Allows the recipient to seek clarification |
| Reason for referral and the specific question being asked | The single most important element; "please see and treat" is not a referral question |
| Relevant history — presenting complaint, duration, relevant medical history, medication, allergies | Prevents repetition and unsafe prescribing |
| Examination findings, including negative findings | Establishes the baseline |
| Investigations already performed, with radiographs attached or made available | Avoids repeat exposure, which IR(ME)R requires |
| Treatment already provided and the response to it | Avoids repeating failed treatment |
| Urgency and the pathway being used | Determines triage |
| Patient's understanding and expectations | Prepares the recipient for the conversation |
An urgent suspected cancer referral must be marked clearly as such so that the patient is seen within the two-week standard. Sending it as a routine referral because the practitioner is uncertain is a recognised source of avoidable delay.
Referrals must be transmitted securely. In the NHS this means an approved secure system or an appropriately secured email account, and never an unsecured personal email account.
Information Governance
- Dental records are personal data and, because they concern health, special category data under UK GDPR requiring a lawful basis and an additional condition for processing.
- Access on a need-to-know basis; looking up a record out of curiosity is a disciplinary and potentially criminal matter.
- Data breaches must be handled under the practice policy, with notification to the Information Commissioner's Office within 72 hours where the breach is likely to result in a risk to individuals.
- Patients have a right of access to their records, normally free of charge and within one month.
- Retention periods follow the NHS Records Management Code of Practice: adult dental care records are retained for 15 years, and children's records until the patient's 25th birthday (or 26th if they were 17 when treatment concluded).
Communication Within the Dental Team
Outcome 4.1 requires appropriate communication with colleagues about direct patient care, oral health promotion, the day-to-day working of the practice, its wider contribution, and raising concerns when problems arise.
Practical elements examined in Paper B:
- Clear laboratory prescriptions — a written prescription is a legal requirement for a custom-made device, and must specify the design, materials and shade unambiguously.
- Delegation within scope of practice — work may only be delegated to a registrant trained, competent and indemnified for it, and the delegating dentist retains overall responsibility for the treatment plan.
- Handover and continuity — where a course of treatment is shared between clinicians, the records must allow another clinician to continue safely.
- Structured escalation — tools such as SBAR (Situation, Background, Assessment, Recommendation) give a compact structure for urgent communication with a medical colleague or an emergency service.
- Feedback — outcome 4.3 requires giving and receiving effective feedback, which means specific, behaviour-focused and timely comment rather than personal criticism.
Exam link. A stem describing a referral letter consisting only of the words "please see and treat" is testing whether you can identify the missing elements. The expected answer names the specific clinical question, relevant history and findings, investigations performed, urgency and the patient's expectations.
What a Dental Record Must Contain
Records are examined because they are the evidence of everything else. A contemporaneous UK dental record should contain the medical history and its updates, the presenting complaint and history, the results of examination including soft tissue examination and BPE, the radiographs taken with their justification and report, the diagnosis, the options discussed including the option of no treatment with their risks, benefits and costs, the consent obtained, the treatment provided with materials, batch numbers where relevant and local anaesthetic used, post-operative instructions, the review arrangements, and any failed or cancelled appointments and advice given by telephone. Entries must be contemporaneous, accurate, legible and attributable, and amendments must be made by addition with a date rather than by alteration or deletion.
Retention periods are examinable: NHS guidance in England is to retain adult dental records for a minimum of 15 years after the last entry, and records for children until their 25th birthday, or their 26th if the last entry was made when they were 17. Records are subject to UK GDPR, and a patient exercising a subject access request is entitled to a copy, normally free of charge and within one month.
Writing an Effective Referral
A referral is a clinical handover and carries the same duty of care as any other act. It should identify the patient fully, state the urgency and the reason for referral clearly, give a concise relevant history including the medical history and current medication, state what has already been done and what the patient has been told, enclose or make available relevant radiographs and photographs, and give the referrer's contact details. Urgent suspected cancer referrals must be made on the two-week-wait pathway with the relevant proforma, and the referring clinician remains responsible for confirming that the referral has been received and acted upon — "I referred them and heard nothing" is not an adequate defence and is a recognised source of serious harm.