Direct Access Records for Hygienists and Therapists (UK): What to Document

What the GDC says direct access is

The GDC explains that patients "have the option to access care from different members of the dental team, without needing to see a dentist first". Before 2013 a referral from a dentist was required for members of the wider dental team to provide care.

For hygienists and therapists the GDC's wording is: "Dental hygienists and dental therapists can carry out their full scope of practice (except tooth whitening) without referral from a dentist." It adds that they "should not be pressured to work in this way as providing direct care to patients is an option", and that those who prefer to treat on referral from a dentist may do so.

The GDC expects everyone working this way to be trained, competent, and indemnified or insured for the care they provide, to work within their scope of practice, and to keep following GDC guidance including the Standards for the Dental Team and the Scope of Practice.

Who is responsible for the patient, and what the note should show

The GDC says overall responsibility depends on who is treating the patient: "If the patient is only seeing a dental care professional, then that individual would be responsible." If the patient is under the care of the dental team, including a dentist who is prescribing or directing treatment, the dentist has overall responsibility.

The GDC's Standards for the Dental Team (Standard 4.1.1) require complete and accurate patient records, including an up-to-date medical history, each time you treat a patient. The following list is Nosht's suggestion for turning that into a direct access note; the GDC does not prescribe a format:

• How the patient came to be seen: self-presented under direct access, or on referral from a named dentist.
• The medical history, reviewed at this visit.
• Consent for the treatment, recorded before it starts. The GDC says consent "must be obtained from the patient for all treatment undertaken and for any referral to other members of the dental team".
• Findings, diagnosis and treatment, all within your scope of practice.
• Any referral, with the reason and the fact that the patient consented to it (see below).
• Your name or initials as the treating clinician (Standard 4.1.4).

Recording a referral to a dentist

The GDC says that when you provide care by direct access you need "clear arrangements in place to refer patients to dentists if those patients need treatment which only dentists can provide". For referral records it says:

• "The need for referral should be explained to the patient and valid consent obtained."
• "The reason for the referral and the fact that the patient has consented to it should be recorded in the patient's notes."
• "Relevant clinical information, including copies of radiographs, should be provided with the referral."
• If a patient declines a referral, "the possible consequences of this should be explained to them and a note of the discussion made in the patient's records".

If you refer to a dentist you have no arrangement with, the GDC says to set out for the patient, in writing, the treatment undertaken and the reasons why they should see their dentist. Standard 4.1.6 separately requires an accurate record of any referral in the patient's notes.

Radiographs under direct access

The GDC says there "should also be referral arrangements in place to make sure a dentist is available to 'report' on aspects of a radiograph that are out of scope of the dental care professional." If you take or request radiographs, the IR(ME)R 2017 duties on justification and clinical evaluation still apply; see our guide to IR(ME)R 2017 in dental notes.

Multi-site and independent practice

For a multi-site set-up the GDC says there "should be formal arrangements such as standard operating procedures in place for the transfer and updating of records, referrals and communication between professionals". For independent practice it says to have clear referral arrangements, made clear in practice literature, and notes that the data protection position may change: "they will have more responsibility", so check how data protection law applies to you.

Notes templates for the visit

Sources

• GDC: Direct access (accessed 18 October 2026)
• GDC: Scope of Practice guidance (revised guidance in effect from 1 November 2025) (accessed 18 October 2026)
• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
• The Ionising Radiation (Medical Exposure) Regulations 2017 (SI 2017/1322) (accessed 18 October 2026)