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.