FGDP Guidelines for Dental Record Keeping: Complete UK Guide (2026)

The CGDent Clinical Examination and Record-Keeping guidelines (first published by FGDP(UK)) are the recognised UK good-practice reference for dental records. The College of General Dentistry (CGDent) says the Care Quality Commission expects dental practices in England to comply with their recommendations when recording medical history, assessing needs, and planning and recording care. Each recommendation is graded A (Aspirational), B (Basic) or C (Conditional).

The CGDent (formerly FGDP(UK)) Clinical Examination and Record-Keeping guidelines are published alongside the GDC Standards for the Dental Team, providing the practical detail that the GDC's high-level principles lack: exactly what to document, when, and to what standard.

While the GDC tells you that you must keep complete and accurate records, the FGDP tells you how. Every element of a dental record — from medical history updates to radiograph justification — is graded, categorised, and assigned a minimum standard. Understanding this framework is not optional: it is the benchmark against which your records will be judged in any complaint, investigation, or audit.

What is FGDP(UK)?

The Faculty of General Dental Practice (UK) was established in 1992 as part of the Royal College of Surgeons of England. In 2021, FGDP(UK) separated from RCSEng to form the College of General Dentistry (CGDent) — an independent professional body for dentistry. The FGDP name remains widely used because the guidelines themselves were published under the FGDP brand, and they continue to be referenced by that name in regulatory and legal contexts.

The FGDP's influence on UK dental practice is substantial. Their standards are cited in:

• GDC fitness to practise hearings — expert witnesses and panel members routinely reference FGDP criteria when assessing whether a registrant's record keeping met the expected standard
• CQC inspections — CQC inspectors review a sample of records as evidence under the safe and well-led key questions. CGDent states that its record-keeping recommendations reflect what CQC expects of practices in England
• Dental indemnity investigations — the DDU, MPS, and Dental Protection all use FGDP standards to assess the defensibility of clinical records in medico-legal claims
• Practice audits and appraisals — record-keeping audits using FGDP criteria are a recognised form of clinical audit for CPD and appraisal

In practical terms, the FGDP standards are the closest thing UK dentistry has to a universally accepted record-keeping specification. They are not statutory law, but they are treated as the professional standard in virtually every context where record quality is assessed.

The A/B/C grading system

The CGDent (formerly FGDP(UK)) Clinical Examination and Record-Keeping: Good Practice Guidelines (3rd edition) grade each recommendation, not each record:

• A — Aspirational: best practice.
• B — Basic: the expected baseline.
• C — Conditional: applies only in some circumstances.

These are professional good-practice guidelines, not law. Any 1/2/3 or A/B/C score you give a finished record in your own audit is a local scoring convention, not the CGDent grading.

What FGDP says must be recorded

The FGDP guidelines provide detailed requirements for different types of clinical encounter. The following sections summarise the key documentation requirements, drawn directly from the Clinical Examination and Record-Keeping standards.

At every examination

These are Grade B (Basic) requirements for every new patient and recall examination:

• Medical history — updated and confirmed at every visit. The record must show that the medical history was actively reviewed, not simply carried forward from a previous appointment. Any changes to medications, medical conditions, allergies, or hospital admissions must be documented.
• Social history — smoking status (including quantity and duration), alcohol consumption, and occupation where clinically relevant. Smoking status in particular is essential for periodontal risk assessment and oral cancer screening.
• Extra-oral examination — assessment of the temporomandibular joints (TMJ), lymph nodes, facial symmetry, and any extra-oral abnormalities. This is frequently omitted from dental records and is a common audit finding.
• Intra-oral soft tissue examination — systematic examination of all oral soft tissues including lips, buccal mucosa, tongue (dorsum, ventral surface, and lateral borders), floor of mouth, hard and soft palate, and oropharynx. This is an essential component of oral cancer screening.
• BPE (Basic Periodontal Examination) — recorded at every routine examination for adult patients. A six-sextant BPE score is the minimum; where scores of 3 or above are recorded, further periodontal assessment is required. The absence of BPE at examination appointments is one of the most commonly cited deficiencies in record audits.
• Hard tissue charting — a complete dental chart recording the status of every tooth present, including existing restorations, caries, missing teeth, and any other pathology. The charting system used should be consistent and recognisable.
• Radiographic findings with IR(ME)R justification — every radiograph must have a documented clinical justification under the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R). The record must include the reason for taking the radiograph, the findings, and a quality assessment grade.

At every treatment visit

These Grade B requirements apply to every appointment where treatment is provided:

• Consent — what was discussed with the patient, including the diagnosis, proposed treatment, alternative options (including no treatment), risks, benefits, and expected outcomes. The record must show that the patient understood the information and agreed to proceed. Generic statements such as "consent obtained" are inadequate — the specific content of the consent discussion should be documented.
• Local anaesthesia — type of anaesthetic used, dose administered, injection site, and batch number where available. Any adverse reactions or difficulties with anaesthesia should be recorded. This is particularly important for medico-legal purposes in nerve injury claims.
• Materials used — brand name, shade (for restorations), and batch number where relevant. This is essential for product traceability and is particularly important for implants, where batch and serial numbers must always be recorded.
• Post-operative instructions given — what the patient was told about aftercare, expected symptoms, warning signs that should prompt them to seek further advice, and emergency contact information. This is a frequent area of deficiency in GDC fitness to practise cases.
• Any complications — if a complication occurred during treatment, it must be documented immediately, including what happened, how it was managed, what the patient was told, and what follow-up arrangements were made.

Administrative requirements

These elements are easily overlooked but are Grade B requirements:

• Date and time — every entry must be dated. Time of treatment is recommended and is essential for emergency appointments or where multiple entries are made on the same day.
• Clinician name and GDC number — the record must clearly identify who provided the treatment. In digital systems this is typically the logged-in user, but it should be verifiable.
• Nurse name where applicable — the dental nurse assisting should be identified. This is relevant for accountability and is increasingly checked in CQC inspections.
• Next appointment and recall interval with rationale — the recommended interval until the next visit, with a brief clinical rationale. Under NICE guidelines, recall intervals should be based on individual risk assessment, not arbitrary timeframes. The rationale for the chosen interval should be documented.

Grade A vs grade B — what separates good from adequate

In the illustrative examples below, a minimal entry that covers the core findings differs from a fuller one that adds more detail, not in what is recorded but in the depth, specificity, and clinical reasoning documented alongside the core findings. The first states what happened; the second explains why, adds clinical context, and demonstrates the clinician's thought process.

BPE documentation

Minimal entry:

BPE (UR/UA/UL over LR/LA/LL): 2 1 2 / 1 2 1

Fuller entry:

BPE (UR/UA/UL over LR/LA/LL): 2 1 2 / 1 2 1. Bleeding on probing noted in UR6 region. Localised gingivitis discussed with patient. OHI reinforced — interdental brushes recommended for upper right posterior. Patient demonstrated technique and confirmed understanding.

Consent documentation

Minimal entry:

Consent discussed for extraction UR8. Risks explained including pain, swelling, bleeding, infection, dry socket. Patient agreed to proceed.

Fuller entry:

Consent discussed for extraction UR8. Treatment options: (1) extraction, (2) monitor. Extraction recommended due to recurrent pericoronitis — 3 episodes in past 6 months. Risks explained: pain, swelling, bleeding, infection, dry socket, OAC given proximity to maxillary sinus on radiograph. Patient asked about recovery time — advised 3-5 days for initial healing. Patient understood and consented verbally. Written information leaflet provided.

Soft tissue examination

Minimal entry:

Soft tissue examination — NAD.

Fuller entry:

Systematic soft tissue examination: lips, buccal mucosa, tongue (dorsum, ventral, lateral borders), floor of mouth, hard and soft palate — no abnormality detected. Submandibular and cervical lymph nodes palpated bilaterally — no lymphadenopathy. Patient advised regarding self-examination for oral changes.

In each case, the first entry records the core finding. The second goes further by documenting clinical reasoning, patient interaction, and specific anatomical detail. CGDent grades its recommendations, not completed records, so neither entry is a "Grade A" or "Grade B" record. Fuller entries can help show what was done and why, but no entry guarantees any outcome in a complaint or claim.

Common FGDP failures

The following deficiencies leave out Basic (B) recommendations — the expected baseline. These are the failures most frequently identified in dental record audits, CQC inspections, and GDC fitness to practise cases where FGDP criteria are applied (see also our guide to medico-legal dental notes).

• No BPE at examination appointments — BPE is a Grade B requirement at every routine examination. Its absence is a common audit finding and is particularly damaging in cases involving undiagnosed or untreated periodontal disease.
• No soft tissue examination documented — failure to record that a systematic soft tissue examination was performed. This is a significant concern given the importance of oral cancer screening at every examination appointment.
• No radiograph justification (IR(ME)R) — recording that a radiograph was taken without documenting the clinical reason for taking it. This fails both FGDP standards and the legal requirements of the Ionising Radiation (Medical Exposure) Regulations.
• Vague treatment notes — entries such as "filling done" or "extraction carried out" without specifying the tooth, surfaces, materials, anaesthetic, technique, or any complications. These records miss the Basic recommendations because they do not contain sufficient detail for another clinician to understand what was done.
• No consent discussion documented — proceeding to treatment without recording that consent was obtained, what options were discussed, or what risks were explained. This is the most serious documentation failure in terms of medico-legal risk.
• Medical history not reviewed at recall — carrying forward a previous medical history without documenting that it was actively reviewed and confirmed with the patient. The record must show a conscious check, not a passive assumption that nothing has changed.

How FGDP standards are used in practice

Understanding the FGDP framework in the abstract is one thing; understanding how it is applied in real-world professional contexts is another. The standards function as the benchmark in four key areas:

GDC fitness to practise proceedings. When the GDC investigates a complaint, expert witnesses assess the registrant's records against FGDP criteria. The A/B/C grading system provides a structured, recognised framework for this assessment. Records that consistently leave out Basic recommendations are cited as evidence of substandard practice, regardless of the clinical treatment provided. Published case determinations frequently reference FGDP standards explicitly.

CQC inspections. Care Quality Commission inspectors assess dental practices against five key questions, two of which — "Is the service safe?" and "Is the service well-led?" — directly involve record-keeping quality. CQC may review the practice's record-keeping protocols against CGDent guidance, but it does not audit the clinical content of individual records (CQC dental mythbuster 8). Where poor record keeping contributes to a breach of Regulation 17 (good governance), CQC can find "not all regulations met" and, in serious cases, use its enforcement powers.

Dental indemnity organisations. The DDU, MPS, and Dental Protection all assess the defensibility of clinical records when a claim or complaint is made. Records that follow the FGDP recommendations are substantially easier to defend; records that leave out Basic recommendations may compromise the indemnity organisation's ability to mount an effective defence. Indemnity providers and the CGDent guidance itself both reference these standards.

Practice audits. Record-keeping audits using FGDP criteria are one of the most common forms of clinical audit in UK dental practice. They are accepted for CPD purposes, recognised by CQC as evidence of clinical governance, and used in appraisal and practice governance. A typical audit involves reviewing a random sample of records against FGDP Grade B criteria and calculating the percentage that meet the standard.

Free FGDP-aligned templates (plain text, PMS-paste ready)

The fastest way to bring your records in line with FGDP/CGDent standards is to use structured templates that prompt every required field. We've published free downloadable templates aligned with each procedure type — copy them into your PMS notes field directly:

• Dental examination template — new patient assessment with MHx, BPE, soft tissue, charting, Montgomery consent
• Routine recall exam template — focused on what changed since last visit
• Emergency exam template — SOCRATES pain history + SDCEP-aligned antibiotic decision
• Child dental exam template — paediatric with SDCEP caries risk + safeguarding
• Scale & Polish (PmPR) template — BSP-aligned
• Composite filling template — Montgomery consent + bonding protocol
• Simple extraction template — Montgomery + SDCEP MRONJ/anticoagulant screen
• Root canal treatment template — BES-aligned, rubber dam mandatory
• Radiograph report template — IR(ME)R 2017 justification + structured findings
• Specialist referral letter template — urgency + clinical question + consent

All templates exclude patient demographics (your PMS captures those) and focus purely on the clinical narrative that needs to be defensible. Browse all 48 free templates.

How Nosht helps meet FGDP standards

Consistent compliance with FGDP standards is a structural problem, not a knowledge problem. Most clinicians know what should be documented — the challenge is ensuring it happens systematically at every appointment, under time pressure, with a full patient list. A dental notes app like Nosht addresses this by building FGDP requirements directly into the documentation workflow:

• Templates structured around the CGDent Basic (B) recommendations — the examination and treatment templates include the documentation elements that FGDP classifies as Basic. Consent, medical history review, soft tissue examination, and materials are built into the relevant template sections, not left to memory. Record your BPE in your PMS perio chart.
• Compliance prompts for critical elements — sections for consent discussion, medical history confirmation and soft tissue examination are part of the examination and treatment templates, so a missing one is visible before you copy the note.
• Bulletproof Mode — Bulletproof Mode checks the structured fields of your note against record-keeping rules drawn from UK guidance (FGDP(UK)/CGDent, GDC, NICE, SDCEP and others) as you write, and flags missing items before you copy the note. It is on by default for higher-stakes templates such as extractions, sedation and implants, and you can switch it on for any other template. It checks what is recorded, not the quality of the care.

The goal is not to change how you practise clinically — it is to ensure that the documentation accurately reflects the care you already provide. Notes are copied with one click and pasted into any practice management system, from Dentally to SOE to R4.

Frequently asked questions

Make FGDP-aligned record-keeping your default.Start free trialGet the free exam note template

Further reading

• GDC Dental Records Requirements: What Every Dentist Must Document
• Dental Documentation Guide: FGDP Standards and Best Practice
• What Should Dental Notes Include?