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Good record-keeping is an essential part of dental practice that is required to provide high-quality, safe and effective patient care. It also provides a permanent record of the care of patients that might prove useful in the event of patient complaints or litigation.

The General Dental Council (GDC) ‘Standards for the dental team’ [1] expects patient records to be complete, contemporaneous, clear, accurate and legible. Records can be held either as a paper copy or digitally on a secured computer.

This section provides information on accepted systems of record-keeping, including the storage of records, the records required for dental care of patients, and brief details about conducting an audit of your record-keeping.

Note that patient records must be managed according to the Data Protection Act 2018 [2]; this is covered in more detail in Ethical Practice.

Sources of Information

[1]Standards for the dental team (2013) General Dental Council

[2] Data Protection Act 2018. (c.12). [Online] London. The Stationery Office