GDC Dental Records: What to Record, Retention and IR(ME)R

What does the GDC require in dental records?

The GDC requires that every registered dental professional keeps accurate, complete, and contemporaneous records of all clinical care provided. Under Standards for the Dental Team (2013), Principle 4 — Maintain and Protect Patients’ Information — dental records must be kept securely, for defined retention periods, and must contain sufficient detail for any other registered clinician to understand the clinical picture without explanation from the original clinician. The standard maxim is: if it is not recorded, it did not happen.

This page covers the specific content requirements, the retention periods that currently apply, how IR(ME)R 2017 affects radiograph documentation, and the FGDP/CGDent good-practice grading used in record audit.

GDC principle 4: the regulatory foundation for record keeping

GDC Principle 4 ("Maintain and protect patients’ information") is the regulatory anchor for dental record keeping. It applies equally to dentists, dental hygienists, dental therapists, dental nurses, clinical dental technicians, dental technicians, and orthodontic therapists. The GDC Standards for the Dental Team (in effect from 30 September 2013) remains the current edition at the time of writing. Under Principle 4, the GDC sets five sub-principles:

• 4.1 — Make and keep contemporaneous, complete and accurate patient records. "Contemporaneous" means recorded at the time of, or immediately after, the clinical event — not reconstructed later. This includes the decision NOT to treat, and the reasons for it.
• 4.2 — Protect the confidentiality of patients’ information and only use it for the purpose for which it was given. This operates alongside the UK GDPR and the Data Protection Act 2018.
• 4.3 — Only release a patient’s information without their permission in exceptional circumstances. The GDC’s guidance (4.3.5) adds that you must document your reasons whenever you decide to release confidential information.
• 4.4 — Ensure that patients can have access to their records; the GDC’s guidance (4.4.1) says to arrange this promptly, in accordance with the law. Separately, UK GDPR requires a subject access request to be answered without undue delay and within one month. Since 5 February 2026 (Data (Use and Access) Act 2025) the search must be reasonable and proportionate, and the clock pauses while you wait for any clarification you have asked for.
• 4.5 — Keep patients’ information secure at all times, whether records are held on paper or electronically.

What must every dental record contain?

The FGDP(UK) Clinical Examination and Record Keeping: Good Practice Guidelines (3rd edition, 2016, now hosted by the College of General Dentistry) sets out the recommended content of a dental clinical record. A record that meets the guidance’s good-practice standards typically includes all of the following at every examination appointment (our FGDP record-keeping guide and dental record audit checklist go further):

• Patient identification — full name, date of birth, NHS number or unique reference, contact details, and the named treating clinician with GDC registration number.
• Medical history — current and complete, updated at every visit; named medications with doses; drug allergies documented with specificity; relevant systemic conditions with clinical implications. ASA physical status classification may be recorded as optional best practice (it is most commonly used for sedation and general-anaesthesia risk assessment rather than as a formal routine record-keeping requirement).
• Examination findings — extra-oral and intra-oral soft tissue assessment (recording negative as well as positive findings); dental charting in a recognised notation. Both Palmer and the FDI/ISO 3950 two-digit system are accepted in UK records — the key requirement is that the notation used is unambiguous and consistent. A six-sextant BPE is recorded at every adult examination (see our BPE scoring guide).
• Treatment planning — diagnosis or differential diagnosis; treatment options discussed (including no treatment); material risks as required under Montgomery v Lanarkshire Health Board [2015] UKSC 11; the patient’s preferred option, sequencing and estimated cost.
• Consent — record that valid consent was obtained before each intervention, the specific information given about material risks, whether consent was verbal or written, and capacity where relevant (MCA 2005; Gillick competence for under-16s). See our guide to documenting consent.
• Treatment record — tooth treated (Palmer or FDI) and surfaces; material used, including batch number and expiry for medicinal products; LA agent, concentration, quantity and vasoconstrictor; radiographs taken (see IR(ME)R 2017 below); complications; advice given.

Dental record retention periods: how long must you keep records?

The 2023 change, confirmed: In 2023 NHS England updated the Records Management Code of Practice (the governing framework for health and care records in England), reducing the retention period for dental clinical care records from 15 years to 11 years. The Code’s separate children’s-records rule gives the 25th or 26th birthday. The "25 vs 26" distinction is not an NHS-versus-private split — it depends on the patient’s age at the conclusion of treatment.

Why retention matters medico-legally: Under the Limitation Act 1980, a patient who was a child at the time of treatment can bring a negligence claim until they are 21 (three years from their 18th birthday). For any patient, the date-of-knowledge rule can start the three years later (s14), and if a patient lacked capacity when the cause of action arose, time does not start to run until they regain it (s28). Destroying records before the applicable retention period expires is a significant litigation and regulatory risk. The Records Management Code is the authoritative source in England — check the current edition at NHS England, as the Code is periodically updated. Scotland, Wales and Northern Ireland publish their own records management codes.

IR(ME)R 2017: radiograph documentation requirements

Every dental radiograph taken in a UK practice must be justified, performed, and clinically evaluated in accordance with the Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R 2017, often written IRMER; SI 2017/1322), in force from 6 February 2018. IR(ME)R 2017 remains the principal framework and was amended by SI 2024/896, in force from 1 October 2024. For each radiograph, the clinical record must document (our radiograph report template covers each item):

1. Justification — a contemporaneous record that the exposure was clinically justified for this patient at this time, recorded per exposure (not per series). Blanket entries such as "routine radiographs taken" are insufficient.
2. Referrer and practitioner — both must be identifiable from the record. In general practice these are often the same person.
3. Operator — the person who positioned the patient and took the radiograph must be recorded.
4. Clinical evaluation — every radiograph must be evaluated and the findings documented (not merely "film taken").
5. Image quality grading — under the two-point A/N scale from the PHE & FGDP(UK) Safe Use of X-ray Equipment guidance (2nd edition, 2020). A = diagnostically acceptable; N = not acceptable. When an N-grade image is retained rather than retaken, the reason must be documented.
6. CBCT justification — Cone Beam CT requires an enhanced justification record (SEDENTEXCT 2012; FGDP Selection Criteria for Dental Radiography, 3rd edition, 2018), stating why cross-sectional imaging was required over conventional radiographs.

How does the FGDP/CGDent guidance grade record-keeping standards?

The FGDP(UK) Clinical Examination and Record Keeping: Good Practice Guidelines (3rd edition, 2016) grades each of its recommendations by how strongly it applies — not the finished record. The published grading is:

A failure to meet B- or C-grade recommendations does not, of itself, imply negligence; the grading distinguishes essential baseline practice from aspirational best practice. (Some practices use their own 1/2/3 or red/amber/green ratings when auditing completed records, but that is a local audit convention — it is not the FGDP/CGDent grading and should not be presented as such.)

In a CQC inspection, inspectors review a sample of clinical records and assess them against recognised record-keeping standards under the Single Assessment Framework (CQC began assessing dental practices under it from 13 May 2024). In a GDC fitness-to-practise investigation, record quality is frequently a secondary finding even when the primary allegation relates to clinical treatment.

How Nosht supports GDC-compliant record keeping

Nosht provides 50 structured clinical note templates built around GDC Standards, FGDP/CGDent Clinical Examination and Record Keeping requirements, and IR(ME)R 2017 documentation obligations. Templates include prompted fields for medical history, Montgomery-aligned consent, local anaesthetic (agent, dose, batch, expiry) where LA is used, radiograph justification and quality grading, and the treatment record. BPE charting stays in your practice management system.

Templates are completed by the clinician at the chairside — Nosht is not an AI audio scribe and does not transcribe or process patient speech. Your clinical notes carry no patient identifiers. The exceptions are referral letters (patient name and date of birth) and sending a leaflet (the patient's email or phone number). The completed note is pasted into your practice management system, and is copy-paste compatible with all major UK dental software. See the dental notes app, or the dental abbreviations guide for the notation used in records.

Frequently asked questions

Further reading

• BPE Scoring Guide — documenting the BPE in your records.
• CQC Dental Inspection Guide — how records are assessed in inspections.
• Dental Abbreviations — the notation and shorthand used in records.
• GDC-aligned note templates — structured records built around GDC and FGDP/CGDent requirements.