Record-Keeping for Dental Therapists (UK): Scope & Dento-Legal Notes

The short answer: what a therapist must document

A dental therapist records to the same standard as a dentist: at each appointment, an updated medical history; the presenting complaint or reason for attendance; clinical findings (including BPE and soft-tissue screening where indicated); the treatment carried out with tooth notation, materials, batch numbers and local-anaesthetic details; consent to the Montgomery standard; advice and recall; and — critically for a therapist — a clear record that each task fell within scope and competence, plus any referral for work outside your scope such as extraction of permanent teeth (GDC, 2013; GDC, 2025).

GDC Principle 4 applies to therapists in full

As a GDC registrant, a dental therapist is bound by Principle 4 of Standards for the Dental Team (2013): make and keep contemporaneous, complete and accurate records; protect confidentiality; allow patient access; keep records secure. There is no "lighter touch" version for dental care professionals — in a complaint, claim or fitness-to-practise investigation, a therapist's notes are assessed to the same standard as a dentist's (GDC, 2013).

Scope of practice and what your notes must prove

The GDC's revised Guidance on Scope of Practice (effective 1 November 2025) is competency-based and no longer lists fixed indicative tasks; it puts the onus on each registrant to judge their own training and competence. For a therapist, the record has therefore become the primary evidence that a given procedure was within your scope and that you were competent and indemnified to carry it out (GDC, 2025).

A dental therapist's clinical scope typically includes direct restorations on primary and permanent teeth, extraction of primary (deciduous) teeth, pulp therapy (such as pulpotomy) on primary teeth, placing preformed crowns on primary teeth, and the full range of periodontal and preventive care that hygienists provide. It does not include the extraction of permanent teeth or treatment beyond your registered title and competence. Your notes should make clear, for each procedure, that it fell within this scope.

Restorations, extractions of primary teeth and local anaesthesia

For direct restorations, record the tooth and surfaces, the diagnosis and indication, the material used with batch number and expiry, the local anaesthetic agent, dose, batch and expiry, and the consent discussion. For extraction of a primary tooth, record the indication, that it is a primary tooth, consent (including the parent's where the patient is a child), the technique and any complications. FGDP/CGDent (2016) sets out the recognised content baseline that applies to therapists as it does to dentists (FGDP/CGDent, 2016).

Direct access: careful triage and referral

Direct access has been permitted in the UK since 1 May 2013 and is preserved by the 2025 scope guidance: a patient can see a therapist without a dentist's referral or prescription (GDC Direct Access, 2013; GDC, 2025). It does not widen your clinical scope — it increases your documentation responsibility, because no dentist gatekept the appointment. Record the basis of attendance (self-referral or dental referral), a full medical and dental history, your findings within your examination scope, and your explicit assessment of whether the patient needs to see a dentist.

Medicines, exemptions and indemnity

Therapists are not independent prescribers, but suitably trained therapists may supply and administer certain medicines under the Human Medicines Regulations 2012 exemptions introduced by SI 2024/729 (in force 26 June 2024). Where you administer such a medicine — for example fluoride varnish or local anaesthetic — be able to demonstrate the legal basis (exemption, PGD or prescription) and record the product, dose, batch and expiry (NHS England, 2024; legislation.gov.uk, 2024).

Retention, CQC and the devolved nations

Therapist records follow the same retention as all dental records: under the NHS England Records Management Code of Practice (2023), adult records are kept for at least 11 years from the last entry, and records for patients treated as children until the 25th birthday — or the 26th if the patient was 17 at the conclusion of treatment — or 11 years, whichever is longer (NHS England, 2023). In England, records are reviewed by the CQC under the Single Assessment Framework (in use for dental practices since 13 May 2024); Scotland, Wales and Northern Ireland use HIS, HIW and RQIA (CQC, 2024).

How Nosht supports therapist documentation

Nosht's structured templates cover the breadth of therapist practice — restorations, primary-tooth procedures, periodontal assessment and instrumentation, fluoride and sealants, direct-access intake and referral — prompting the fields a defensible therapist record needs, including scope, consent, materials and referral. Nosht is decision-support, not a patient-record system: your clinical notes hold no patient identifiers, and clinical specifics should be verified against current BNF, SDCEP and NICE guidance. What you may and may not do under your scope is a regulatory matter — Nosht is documentation software, not clinical or regulatory advice.

Do dental therapists keep the same records as dentists?

Yes. Under GDC Principle 4 (2013), dental therapists keep records to exactly the same standard as dentists — contemporaneous, complete, accurate and secure. There is no reduced standard for dental care professionals. In addition, because a therapist works within a defined scope, the record must evidence that each procedure fell within that scope and your competence (GDC, 2013; GDC, 2025).

What falls within a dental therapist's scope for record-keeping purposes?

A dental therapist's scope typically includes direct restorations on primary and permanent teeth, extraction of primary (deciduous) teeth, pulp therapy such as pulpotomy on primary teeth, preformed crowns on primary teeth, and the full periodontal and preventive remit. It does not include extraction of permanent teeth or work beyond your registered title and competence. Since the 2025 scope guidance is competency-based, your record is the primary evidence that a task was within scope and that you were competent to do it (GDC, 2025).

What must a therapist record when working under direct access?

Record the basis of attendance (self-referral or dental referral), a full current medical and dental history, your clinical findings within your examination scope, your explicit assessment of whether the patient needs a dentist, the treatment carried out with consent, and any onward referral. Direct access has been permitted since 1 May 2013 and does not widen your scope — it increases the documentation burden because no dentist gatekept the appointment (GDC Direct Access, 2013).

How does a therapist document a referral for a permanent-tooth extraction?

Extraction of permanent teeth is outside a therapist's scope, so it must be referred to a dentist. Record the finding that prompted the referral, who you referred to, the urgency and timeframe, and exactly what you advised the patient. An unrecorded referral is the most common and most serious therapist record-keeping vulnerability, particularly under direct access where no dentist independently saw the patient (GDC, 2013, Principle 6).

Can dental therapists prescribe or administer medicines?

Therapists are not independent prescribers. However, suitably trained therapists may supply and administer certain medicines — such as fluoride varnish and local anaesthetic — under the Human Medicines Regulations 2012 exemptions introduced by SI 2024/729 (in force 26 June 2024). Where you administer such a medicine, be able to show the legal basis (exemption, PGD or prescription) and record the product, dose, batch and expiry (NHS England, 2024).

How long must a dental therapist keep records?

The same retention periods apply as for all dental records: under the NHS England Records Management Code of Practice (2023), adult records are kept for at least 11 years from the last entry, and records for patients treated as children until the 25th birthday — or the 26th if the patient was 17 at the conclusion of treatment — or 11 years, whichever is longer. Records connected to a complaint, claim, GDC investigation or inquest are never destroyed until those proceedings conclude (NHS England, 2023).