The dental treatment record: what it must contain and how to keep it properly

The value of a treatment record rarely shows on an ordinary day. It shows on a difficult one: a complaint, an inspection, or a patient returning after two years with no memory of what was done. At that point the record stops being paperwork and becomes the only thing that shows what actually happened in the practice.

This guide explains what the treatment record is, how it differs from the treatment plan, what it should contain, what the law requires about keeping and retaining it, and how to keep it properly, whether you work on paper or digitally.

The legal references in this article apply to Romania. For a practice established in another country the applicable obligations are different and must be verified separately. This article is informational and does not replace legal advice.

What the dental treatment record is

The treatment record, also called the patient record or dental chart record, is the document in which the care actually delivered to a patient is set down: who they are, what conditions they have, the diagnosis established, the treatment received and how it progressed.

It serves three purposes at once. It is a clinical document, because it keeps care continuous no matter which practitioner in the team treats the patient. It is evidence of the work done, because it attests what was performed, when, and with whose consent. And it is the patient's clinical memory, which anyone on the team can return to: history, previous treatments, observations.

When the record is missing or incomplete, all three disappear together.

The treatment record and the treatment plan are not the same thing

The two are often confused, although they look in opposite directions.

The treatment plan describes what is going to be done: the proposed stages, the procedures, the estimated costs, the alternatives. It is drawn up at the start and discussed with the patient.

The treatment record sets down what was actually carried out: each session, each procedure, each clinical observation, as the treatment progresses.

The plan looks forward, the record looks back. In a well-organised practice the two do not duplicate each other: the procedures from the plan move into the record as they are performed, without being retyped.

What the treatment record contains

Use the list below as a checkpoint, whatever medium you work on.

**The patient's identification details.** Name, surname, personal identification number, contact details, age. For minors, the details of the legal representative.

**The medical history.** General conditions relevant to dental treatment: cardiovascular disease, diabetes, coagulation disorders, pregnancy. This information can decisively change the choice of anaesthetic and the treatment strategy.

**Allergies.** The highest-risk entry. Any known hypersensitivity, particularly to anaesthetics or antibiotics, must be recorded visibly.

**Habits and risk factors.** Smoking and alcohol consumption affect healing and the success rate of certain treatments, including implants.

**Dental history.** Previous treatments, existing work, radiographs, oral surgery procedures and how long ago they were performed.

**The clinical examination.** Dental and periodontal status, observations on each tooth, clinically significant parameters. Before higher-risk procedures, vital signs such as blood pressure are sometimes noted as well.

**The diagnosis.** Clearly stated, as the basis for the treatment plan.

**The treatment performed, session by session.** The date, the procedures carried out, the materials used, the practitioner who performed the treatment, the progress and any complications.

**Informed consent.** The element that carries the most weight when a dispute arises. The record must attest that the diagnosis, the proposed treatment, the risks and the alternatives were explained to the patient, and that the patient understood and accepted them.

**Data protection documents.** The agreement for processing personal data, health data being sensitive data.

What the law requires in Romania

Four distinct obligations converge on the treatment record. The provisions below are those applicable in Romania.

**Keeping the record.** The Code of Ethics for Dental Practitioners, adopted by Decision no. 6/1AGN/2021 of the Romanian College of Dental Practitioners, requires under article 34 that the practitioner draw up primary evidence documents for each patient and record every medical activity in an appropriate document, concluded by a written clinical entry.

**Consent.** Law no. 95/2006 provides, in Title XVI, Chapter III, article 649, that the patient's written agreement is requested before they undergo prevention, diagnosis or treatment methods carrying potential risk, after those methods have been explained. The information must cover the diagnosis, the nature and purpose of the treatment, its risks and consequences, viable alternatives with their risks, and the prognosis without treatment. The legal age for giving consent is 18, with the exceptions the law provides for minors. The same requirement appears in article 50 of the Code of Ethics.

**Retention.** The Code of Ethics provides under article 35 that clinical documents are kept in the archive for five years from the date of last contact with the patient, unless the law provides another term. Added to that term is the practice's own archival schedule: Law no. 16/1996 on the National Archives requires, under article 8, every creator of documents to group them by retention term in a schedule approved by the National Archives.

**Data protection.** The General Data Protection Regulation places data concerning health in the special category of data whose processing is permitted only under the conditions set out in article 9. Article 32 requires technical and organisational measures appropriate to the risk, among them the ability to restore access to data after a physical or technical incident. This regulation applies throughout the European Union.

Inspection sits alongside these: Law no. 95/2006 provides under article 27 that medical service providers must allow access to personnel authorised to inspect, who have a right of access to documents and information.

Beyond the detail of each rule, the practical conclusion is that the record must exist for every patient treated, be complete, be findable even years later, and be protected against loss and against unauthorised access.

Where paper falls short

Paper meets the first condition, existence, but frequently stumbles on the other three.

Retrieval is the first problem. A paper record in a cabinet holding hundreds of files is hard to find quickly, especially when the patient returns after several years or is taken over by another practitioner in the team.

Completeness is the second. On paper, entries get skipped, handwriting becomes illegible, and consent forms sometimes go missing between pages.

Protection is the third. Paper burns, gets wet and gets lost, and a single lost copy means a permanently lost history. A physical file in a drawer rarely provides the protection against unauthorised access that article 32 of the regulation requires.

How to keep the record properly

A few principles apply whatever software you use.

Complete it during the session, not afterwards. A record completed while the work is fresh is more accurate and does not depend on memory.

Connect the record to the treatment plan. Procedures from the plan should move into the record as they are performed, without re-entry.

Document tooth by tooth. Observations per tooth, not only on the patient in general, increase clinical precision and the record's usefulness two years later.

Collect consent and medical history in signed form. Ideally the patient completes and signs them before the appointment, and the document lands directly in their file.

Restrict access. Not everyone on the team needs access to everything, and roles and permissions support the requirement to protect sensitive data.

How the treatment record works in AtriumApp

We build your treatment record as part of the patient's electronic file, which brings together personal data, medical histories, treatments performed, attached documents and clinical notes.

Each record is linked to the appointment at which the treatment was performed, and a patient's records appear in reverse chronological order, with the practitioner who performed the treatment and the sterilization packages used.

You add procedures from the treatment plan straight into the record by ticking them, without retyping. Once you save the record, those procedures are automatically marked as performed and the plan's completion percentage updates.

On the dental chart you can rotate the model, select several teeth at once and document the condition of each. The adult chart uses two-digit international numbering, and a separate diagram exists for children. You can write an observation for a specific tooth, and the history shows you everything ever done on that tooth.

The patient agreement, the medical history form and the data processing agreement are completed through a secure link sent by SMS or a code scanned at reception. The patient signs on screen, by touch on a phone or tablet or with a mouse on a desktop, and the signed document is saved automatically as a PDF in their file.

The servers the application runs on are allocated in Romania, therefore within the European Economic Area, and data is backed up daily. Access is controlled by role, so each team member sees only what they need.

The platform subscription is a flat 140 EUR per month, preceded by a two-week free trial of the full platform that needs no credit card to start. There is no mandatory long-term commitment and you can cancel at any time. A second location is 100 EUR per month, and further locations receive a custom offer. Full terms are on the pricing page.

Commercial terms differ by market: for practices established in Romania, full access is offered free of charge and guaranteed contractually for five years.

If you want to see what a completed record looks like, the simplest route is to start from the electronic patient file and follow a treatment from the treatment plan through to the record that documents it.

Frequently asked questions

What must a dental treatment record contain?

Identification details, medical history, allergies, risk factors, dental history, clinical examination, diagnosis, the treatment performed session by session and the patient's informed consent, together with the data processing documents. In Romania, the Code of Ethics for Dental Practitioners requires, under article 34, primary evidence documents for every patient.

What is the difference between the treatment record and the treatment plan?

The treatment plan describes what is going to be done, with stages and estimated costs, and is discussed with the patient at the start. The treatment record sets down what was performed, session by session, as the treatment progresses.

How long must a patient record be kept?

In Romania, the Code of Ethics for Dental Practitioners provides under article 35 that clinical documents are kept in the archive for five years from the date of last contact with the patient, unless the law provides another term. Each practice also sets its terms through its own archival schedule, approved by the National Archives under Law no. 16/1996. In another country the applicable term differs and must be verified separately.

Is informed consent mandatory?

Yes. In Romania, Law no. 95/2006 provides under article 649 that the patient's written agreement is requested before prevention, diagnosis or treatment methods carrying potential risk, after they have been explained. The same obligation appears in article 50 of the Code of Ethics for Dental Practitioners.

Sources

• Law no. 95/2006 on healthcare reform (Romania), Title XVI Chapter III articles 649-651 and Title I article 27.
• Code of Ethics for Dental Practitioners, CMSR Decision no. 6/1AGN/2021, articles 34, 35 and 50.
• Regulation (EU) 2016/679 on data protection, articles 9 and 32.
• Law no. 16/1996 on the National Archives (Romania), article 8.