What should dental notes include?

Dental notes should include patient identification, date and time, presenting complaint, medical history review, clinical findings, diagnosis, treatment plan discussed with patient, consent obtained, treatment performed, materials used, anaesthetic details, post-operative instructions, and follow-up arrangements.

Can dental notes software help with GDC complaints?

Yes. Structured dental notes software ensures documentation completeness — consent discussions, risk disclosures, treatment alternatives, and post-operative instructions are systematically prompted.

Dental Notes: Complete, Compliant, Consistent

Dental notes are the written clinical records that document every patient interaction, examination finding, diagnosis, treatment plan, and procedure in a dental practice. Under GDC Standards, they must be contemporaneous, legible, and comprehensive enough to withstand regulatory scrutiny.

What Should a Dental Note Include?

Patient identification and date
Presenting complaint
Medical history review
Clinical examination findings
Diagnosis
Treatment options discussed
Consent
Treatment performed
Post-operative instructions
Follow-up

FAQ

How long should dental records be kept?

In the UK, dental records should be retained for a minimum of 10 years after the last entry, or until the patient reaches age 25 for children.

What are the GDC standards for dental record-keeping?

The GDC Standards for the Dental Team require that clinical records are complete, accurate, and contemporaneous.

Last updated: March 2026