What must a dental record contain under GDC standards?

Under GDC Standards for the Dental Team (2013, Principle 4), a dental record must contain: the patient’s identity and contact details; a current, updated medical history including medications and allergies; findings from every examination (including a six-sextant BPE for adults); treatment options discussed and the patient’s preferred option; a record of valid consent; the specific treatment carried out (tooth notation, material, LA agent and dose, batch number and expiry); radiograph justification and clinical evaluation; and any advice given. Every entry must be contemporaneous.

What is GDC Principle 4 in dentistry?

GDC Principle 4 — "Maintain and protect patients’ information" — is one of nine principles in the GDC’s Standards for the Dental Team (2013). Under Principle 4, dental professionals must record all clinical care; keep records that are accurate, complete, legible, and contemporaneous; maintain confidentiality; keep records for defined retention periods; and respond to subject access requests. It applies equally to dentists, hygienists, therapists, dental nurses, and all other registrants.

What do IRMER 2017 radiograph requirements mean for dental records?

IRMER 2017 requires that for every dental radiograph the record contains: a justification for the exposure specific to that patient and appointment; the identity of the referrer and practitioner; an image quality grade (A — diagnostically acceptable, or N — not acceptable, under the PHE/FGDP 2020 two-point scale); and a clinical evaluation of the findings. "Film taken" is insufficient. IRMER 2017 remains the principal framework; it was amended (not replaced) by SI 2024/896, in force 1 October 2024.

What is the FGDP/CGDent grading system for dental records?

The FGDP(UK) Clinical Examination and Record Keeping guidelines (3rd edition, 2016, now hosted by CGDent) grade their recommendations — not finished records — as A (aspirational), B (basic / essential baseline), or C (conditional / situation-specific). There is no official FGDP/CGDent "Grade 1/2/3" scale for rating completed records; any such 1/2/3 rating is a local audit convention, not the FGDP system.

What the GDC Requires in Dental Records: Principle 4, Retention Periods, and IRMER 2017

Clinically reviewed by Mohammad Noori, GDC No. 310862. Last reviewed: June 2026.

The General Dental Council (GDC) requires every registered dental professional to maintain accurate, contemporaneous, and complete patient records under Standards for the Dental Team (2013), Principle 4 — Maintain and Protect Patients’ Information.

Dental record retention periods

For adult patients, dental records must be kept for at least 11 years from the date of the last entry — the period set by NHS England’s Records Management Code of Practice, reduced from 15 years to 11 years in 2023. For patients who were children when treated, records are kept until the patient’s 25th birthday — or the 26th birthday if the young person was 17 when treatment concluded — and, per defence-organisation advice, not less than 11 years from the last entry. The 25-versus-26 distinction depends on the patient’s age at the conclusion of treatment, not on whether the practice is NHS or private.

Every dental radiograph must be justified, performed and clinically evaluated under IRMER 2017 (in force 6 February 2018; amended by SI 2024/896 from 1 October 2024), with an A/N image-quality grade recorded per the PHE/FGDP 2020 two-point scale.

Last updated: June 2026

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