Clinical examination & record-keeping: Part 1: Dental records

Key Points

  • Describes what constitutes dental records.

  • Discusses the statutory requirements pertaining to dental records.

  • Highlights the importance of security in dealing with and storing patient records.


This article forms part of a BDJ series of Practice papers on the subject of clinical examination and related record keeping. The series is taken from the Faculty of General Dental Practice UK (FGDP[UK]) 2016 Good Practice Guidelines book on this topic, edited by A. M. Hadden. This particular article, the first in the series, describes what constitutes dental records. The principles are applicable to electronic and handwritten records. Records will fall below acceptable standards when it is not clear to another clinician what was found, planned, discussed, and what treatment carried out.

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  1. 1

    Data Protection Act 1998. London: HMSO, 1998. Available at (accessed November 2017).

  2. 2

    Access to Health Records Act 1990. Available at (accessed November 2017).

  3. 3

    Access to Health Records (Northern Ireland) Order 1993. Available at (accessed November 2017).

  4. 4

    Freedom of Information Act 2000. London: HMSO, 2000. Available at (accessed November 2017).

  5. 5

    Freedom of Information (Scotland) 2002. London: HMSO; 2002. Available at (accessed November 2017).

  6. 6

    Department of Health. Good practice in consent implementation guide: consent to examination or treatment. London: DH, 2001. Available at (Accessed December 2015).

  7. 7

    General Dental Council. Standards for Dental Professionals. London: GDC, 2005.

  8. 8

    Department of Health. Records Management: NHS Code of Practice Part 2, Annex D1. London. DH. 2009.

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    Advice from Medical and Dental Defence Union of Scotland (MDDUS).

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Correspondence to A. M. Hadden.

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Hadden, A., and the FGDP(UK) Clinical Examination and Record-Keeping Working Group. Clinical examination & record-keeping: Part 1: Dental records. Br Dent J 223, 765–768 (2017).

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