Records and informing patients

In detail

The first two of the six criteria on process quality § 6 QSV.

1. Patient history and records

Records must be kept for every patient, in particular of § 19(1) ZÄG:

• the dentally relevant condition on taking them on (history),
• the diagnosis,
• the information given to the patient,
• the kind and extent of treatment, including medicines used and prescribed.

The QSV adds: recorded systematically and traceably; data, prescription pads and stamps protected against unauthorised access and loss; archived for at least ten years; data protection including deletion and disposal; confidentiality agreements with staff and IT firms; assisting staff are informed of treatment-relevant patient data with a potential for danger or complications § 6 no. 1 QSV § 19(3) ZÄG.

Patients may see their records on request and get copies, X-ray duplicates included, for a fee. New since 30 July 2026: a first copy must be provided free of charge § 19(2) ZÄG § 90(20) ZÄG.

2. Communicating with and informing patients

Patients must be informed in particular about § 18(1) ZÄG:

A written treatment and cost plan is required when costs are substantial, when they exceed the chamber's Autonomous Fee Guidelines, or when the patient asks for one § 18(3) ZÄG.

The QSV adds: relevant findings are discussed; required written consents stay traceably in the file; communication with people with learning or speech disabilities is as barrier-free as possible; if there is doubt whether the patient has understood, a companion is involved with their consent; the rules for minors and adult protection law are observed § 6 no. 2 QSV.