General Dental Council. Standards: standards for the dental team. 2013. (accessed August 2022)
Charangowda BK Dental records: an overview. J Forensic Dent Sci. 2010; 2:5-10
NHS England. Dental record keeping standards: a consensus approach. 2019. (accessed August 2022)
FGDP(UK). Clinical examination and record keeping guidelines. 2016. (accessed August 2022)
Department of Health and Social Care. Ionising Radiation (Medical Exposure) Regulations. 2017. (accessed August 2022)
National Institute for Health and Care Excellence. Dental recall: recall interval between routine dental examinations. Clinical guidance 19 (CG19). 2004. (accessed August 2022)
Hitting the mark - accuracy and automatic templates. 2015. (accessed August 2022)
D'Cruz L, Rattan R Electronic clinical dental records: unintended consequences. Br Dent J. 2018; 224:582-583
Data Protection Act 2018. (accessed August 2022)
Access to Health Records Act 1990. (accessed August 2022)
Dental Protection. Record keeping in Wales. 2017. (accessed August 2022)
NHSX. Records management code of practice. 2021. (accessed August 2022)
Care Quality Commission. Dental mythbuster 8: dental care records. 2022. (accessed August 2022)

An update on record keeping

From Volume 49, Issue 9, October 2022 | Pages 771-774


Kate Mortiboy

MChD/BChD, Dental Surgery and BSc Oral Science Dental Officer, Leicestershire Community Dental Services CIC

Articles by Kate Mortiboy

Email Kate Mortiboy


Dentists are required to make and keep accurate dental records of care provided to their patients. As such, dentists should familiarize themselves with data protection legislation and how that impacts their practice. This article discusses the benefits of good record keeping, the use of templates in record keeping, access to and retention of dental records and the benefit of audit to ensure record keeping is meeting current standards.

CPD/Clinical Relevance: An update and overview for the dental team on record keeping and the relevant standards.


Good record keeping is not only a GDC requirement,1 but an expectation for the competent professional practice of all healthcare professionals. In general, the benefits of good record keeping are to:

With an increasing focus on dentistry moving towards a more integrated care pathway approach, adopting a more consistent way of recording patient information is key for better information sharing, care planning and patient safety. The 2019 NHS England and NHS Improvement standards,3 which apply to NHS practices only, were agreed between commissioners, regulators and the profession. However, there has been considerable controversy surrounding them because some elements contradict the FGDP/College of Dentistry guidance.4

The standards3 include three separate tables to show what information is considered essential, aspirational, conditional, or not required for recording in patient records for each of the following scenarios:

Register now to continue reading

Thank you for visiting Dental Update and reading some of our resources. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Up to 2 free articles per month
  • New content available