Record-Keeping for Dentists (UK): A Dento-Legal Guide

The short answer: what a dentist must document

At every appointment a dentist should record: an updated medical history; the presenting complaint; a full examination including soft-tissue/oral-cancer screening and BPE where indicated; radiographs with justification and reporting; a diagnosis and the treatment options discussed; consent to the Montgomery standard; the treatment carried out with tooth notation, materials, batch numbers and local-anaesthetic details; any prescription issued; advice and recall interval; and any referral. The standard is GDC Principle 4 (GDC, 2013), with FGDP/CGDent (2016) as the recognised UK benchmark for content.

GDC Principle 4 for dentists

GDC Principle 4, "Maintain and protect patients' information," is the regulatory foundation. It requires you to make and keep contemporaneous, complete and accurate records, protect their confidentiality, allow patient access, and keep them secure on paper or electronically (GDC, Standards for the Dental Team, 2013). "Contemporaneous" means at the time of, or immediately after, the appointment. The 2013 Standards remain the current edition at the time of writing.

Examination, diagnosis and treatment planning

As the diagnosing clinician, your record must evidence the reasoning, not just the outcome. Document your examination findings specifically — including relevant negative findings — your soft-tissue and oral-cancer screening, your periodontal assessment (BPE, with detailed charting where the code indicates), your radiographic findings, your working diagnosis, and the treatment plan with the reasonable options you discussed. FGDP/CGDent's Clinical Examination and Record Keeping guidelines (2016) set out the recognised content baseline (FGDP/CGDent, 2016).

Consent for irreversible and surgical treatment (Montgomery)

Dentists routinely carry out irreversible and surgical procedures — extractions, endodontics, crown preparations, implants — where the consent record is critical. Under Montgomery v Lanarkshire [2015] UKSC 11, you must document the material risks and the reasonable alternatives discussed for each procedure, tailored to the individual patient (Montgomery v Lanarkshire [2015] UKSC 11).

For example, for a surgical extraction the commonly discussed material risks include pain, swelling, bleeding, dry socket, damage to adjacent teeth, retained roots, oro-antral communication (upper posterior teeth) and nerve injury (lower teeth), alongside the reasonable alternatives including no treatment. Record the specific risks you discussed, the alternatives offered, the expected outcome, and that the patient could ask questions and understood. For higher-risk treatment, pair a signed consent form with a contemporaneous note and, where appropriate, time to reflect.

Prescribing records

Dentists prescribe within their competence, and the prescription is a distinct part of the dento-legal record. When you prescribe, document the indication, the drug, dose, frequency and duration, any relevant checks (allergies, interactions, medical history), and the advice given to the patient. Antimicrobial prescribing in particular attracts scrutiny under antimicrobial stewardship: record why an antibiotic was clinically justified rather than prescribed by default, in line with SDCEP and FGDP guidance.

Radiographs and IRMER

Where radiographs are taken, the Ionising Radiation (Medical Exposure) Regulations 2017 (as amended 2024) require the record to show justification for this patient and appointment, the identity of the referrer, practitioner and operator, an image-quality grade, and a clinical evaluation (report) of the image (IRMER 2017). A radiograph taken but not reported in the notes is a common and avoidable record-keeping gap.

Referrals: closing the loop

When you refer — to a specialist, secondary care or an urgent suspected-cancer pathway — record the finding that prompted the referral, the recipient, the urgency and timeframe, and what you told the patient, including any safety-netting advice. Under GDC Principle 6 you must work in the patient's best interests and refer appropriately; the record is the evidence that you did and that the loop was closed (GDC, 2013).

Retention, CQC and the devolved nations

Under the NHS England Records Management Code of Practice (2023), adult dental records are kept for at least 11 years from the last entry; records for patients who were children when treated are kept until the 25th birthday — or the 26th if the young person was 17 at the conclusion of treatment — or 11 years from the last entry, whichever is longer (NHS England, 2023). Records connected to a complaint, claim, GDC investigation or inquest are never destroyed until those proceedings conclude.

In England, dental practices are assessed by the CQC under the Single Assessment Framework, in use for dental practices since 13 May 2024 (CQC, 2024); Scotland, Wales and Northern Ireland use HIS, HIW and RQIA. As the treating dentist, and often as the practice owner or registered manager, your records are reviewed under the "Safe" and "Effective" quality statements.

How Nosht helps dentists keep thorough records

Nosht provides structured, GDC/FGDP-aligned templates across the full range of general and specialist dentistry — examination, restorative, endodontic, surgical, prosthodontic, implant and more — that prompt the components a defensible dentist's record needs, including diagnosis, options, consent, materials and referral. It is decision-support, not a patient-record system: your clinical notes hold no patient identifiers, and prescribing and clinical specifics should always be verified against current BNF, SDCEP and NICE guidance.

What must a UK dentist record at every appointment?

A dentist should record an updated medical history, the presenting complaint, examination findings (including soft-tissue screening and BPE where indicated), radiographs with justification and a report, a diagnosis and the options discussed, consent to the Montgomery standard, the treatment carried out with tooth notation, materials, batch numbers and local-anaesthetic details, any prescription issued, advice and recall interval, and any referral. The standard is GDC Principle 4 (2013), with FGDP/CGDent (2016) as the benchmark for content.

How should a dentist document consent for an extraction?

Under Montgomery v Lanarkshire [2015] UKSC 11, document the specific material risks discussed — for a surgical extraction these commonly include pain, swelling, bleeding, dry socket, damage to adjacent teeth, retained roots, oro-antral communication for upper posterior teeth and nerve injury for lower teeth — together with the reasonable alternatives (including no treatment), the expected outcome, and that the patient could ask questions and understood. For higher-risk surgery, pair a signed form with a contemporaneous note.

What should a dentist record when prescribing?

Record the indication, the drug, dose, frequency and duration, the relevant safety checks (allergies, interactions, medical history) and the advice given. For antibiotics, document why the prescription was clinically justified rather than issued by default, in line with antimicrobial stewardship. Always verify the prescription against the current BNF/BNFC and SDCEP guidance for the specific patient — documentation prompts do not replace the formulary.

Do dentists have a higher record-keeping standard than DCPs?

No — the standard under GDC Principle 4 (2013) is the same for every registrant. What differs is scope: because dentists diagnose, plan treatment, carry out irreversible and surgical procedures and prescribe, more of their record is diagnosis, consent for irreversible treatment, prescribing and referral. The quality bar (contemporaneous, complete, accurate, attributable) is identical across the team.

What must be recorded for a dental radiograph?

Under IRMER 2017 (as amended 2024), the record must show justification for this patient and appointment, the identity of the referrer, practitioner and operator, an image-quality grade, and a clinical evaluation (report) of the image. A radiograph taken but not reported in the notes is a common, avoidable record-keeping gap.

How long must a dentist keep patient records?

Under the NHS England Records Management Code of Practice (2023), adult records are kept for at least 11 years from the last entry; records for patients treated as children are kept until the 25th birthday — or the 26th if the patient was 17 at the conclusion of treatment — or 11 years from the last entry, whichever is longer. Records connected to a complaint, claim, GDC investigation or inquest must not be destroyed until those proceedings conclude (NHS England, 2023).