How much detail should I include in a patient's records?

To fulfil their primary purpose of supporting patient care, your records should include:

  • histories (medical, dental and social)
  • dental charting
  • findings on examination, including negative findings (eg no teeth tender to percussion)
  • diagnosis
  • information given to patients, as part of the consent discussion
  • agreed treatment plan and consent
  • treatment given
  • any mishaps and complications
  • the date of each entry
  • the identity of the person making it.

Be aware that telephone consultations, handwritten notes, radiographs and correspondence form part of a patient's dental record; complaints correspondence should be filed separately.

Our guide to keeping good clinical records has more information.

This page was correct at publication on 21/01/2022. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.