Beyond note bloat: Could Standard Operating Protocols (SOPs) offer a solution with dental record keeping?

UR3 (M), SOP#5, A2 & SOP#16ai (2.2 ml) 

In this example (caveat SOP references used here are purely for illustrative purposes),  SOP#5 could refer to a standard protocol for the placement of an anterior composite restoration at the mesial surface of an upper right canine tooth, while  SOP#16  could describe local anaesthetic administration, with sub-codes identifying the anaesthetic agent (‘a’) and delivery technique (‘i’). Local variations, such as restorative materials, bonding agents or matrix systems, could be incorporated into tailored, locally agreed SOPs. Treatment modifications, complications encountered, or specific details such as local anaesthetic volumes administered, could then be recorded through supplementary codes or brief free text additions. In this case, the volume of local anaesthetic administered (2.2 ml) and the composite shade selected (A2) are recorded alongside the SOP references. 

Compare this with a conventional and more succinct clinical entry (excluding treatment planning, medical history updates, consent, and shared decision-making discussions): 

UR3: LA 2.2ml (local anaesthetic) administered (noting name of LA) via labial infiltration, labial sulcus. Isolation - cotton wool rolls. Mesial caries removed from UR3, palatal access. Cavity prepared; no pulpal exposure. Etch-and-bond [materials]. Composite placed [material and shade A2], finished and polished. Occlusion checked and adjusted as required. Post-operative instructions given, including risks (insert any further information). 

While detailed documentation will always remain necessary where treatment departs from standard practice, or most likely when recording clinical assessments, treatment planning and consent discussions, much of the documentation associated with routine procedures is inherently repetitive. 

A SOP-referenced approach could: 

• Reduce reliance on templates that may be inaccurate, incomplete, and vulnerable to challenge if they do not properly reflect the care delivered
• Improve consistency between documented records and clinical practice
• Enhance the safe and effective delivery of care 
• Support staff training and onboarding 

Most importantly, it could help clinicians spend less time documenting care and more time delivering it. 

SOP referencing should be viewed as an additional tool – an option for use, rather than a regulatory requirement. It is not intended to replace professional judgement, clinical reasoning, or detailed narrative documentation where these remain necessary. SOPs should not constrain clinical freedom, and there will be valid variation between clinicians and clinical teams in terms of operating protocols, related to their preferred clinical approach and the use of dental materials.  

Looking ahead, the integration of SOP coding within practice management systems, combined with advances in artificial intelligence (AI), could fundamentally reshape clinical record keeping. AI-enabled systems could automatically translate coded entries into comprehensive narratives when required, flag deviations from established protocols, support audit and quality assurance activities, and facilitate the structured analysis of clinical data at scale.  

Such developments have the potential not only to improve efficiency and accuracy, but also to transform the patient record from a retrospective account of care into an active tool for enhancing clinical governance, safety, and continuous improvement. 

Developing SOPs: from concept to consensus 

The use of SOPs is not about creating new clinical standards, rather to reflect established clinical protocols and guidance. 

In this link NHS England » Concise clinical record keeping you will find some examples that have been developed for a small range of common dental procedures and show how treatment-specific SOPs could be linked to standardised recording codes.  

These examples should be viewed as starting points rather than finished products. Individual practices, educational institutions, and healthcare organisations may choose to adapt/tailor SOPs to reflect local requirements, available equipment, workforce skill mix, and patient demographics. 

Over time, a comprehensive library of SOP-referenced procedures could be developed, encompassing a broad range of clinical interventions and sub-procedures. These might include routine processes such as rubber dam placement, local anaesthetic administration, and provisional restorations, through to more complex restorative, surgical and preventive treatments.  

Considerations 

The SOP should also reflect the standard clinical protocols used, otherwise the integrity of the record may be compromised. 

Consideration should be given that there will be a learning curve as clinical teams and services adopt the use of SOPs to support concise clinical record keeping. 

Many aspects of patient care will continue to require detailed narrative records. These include clinical assessments, treatment planning, consent and shared decision-making discussions, atypical presentations, treatment modifications, complications, adverse events etc. Under such situations, a coded SOP reference alone would be insufficient. 

Looking ahead