Dental Record Keeping and Documentation: Meeting the Standards
In a dental complaint, the record often decides the outcome. This guide sets out what a good dental record contains, why contemporaneous notes matter, how to handle corrections, and the privacy, retention and access rules every dental practitioner should know.
Key takeaways
- The shared Code of conduct requires accurate, up-to-date, factual, objective and legible dental records.
- Record the treatment options discussed — including no treatment and referral — not just the treatment performed.
- Make entries contemporaneously; never alter a record after a complaint, and correct transparently.
- Dental records are health information — store them securely under the Australian Privacy Principles.
- Retention is set by state and territory law — generally at least seven years for adults, longer for children.
Why dental records matter
Clinical records are fundamental to safe dentistry and to defending your practice if it is ever questioned. The shared Code of conduct requires practitioners to keep accurate, up-to-date, factual, objective and legible records that report on the care provided. In a complaint, contemporaneous notes are frequently the deciding factor — if a discussion is not recorded, a patient’s account may be accepted over the practitioner’s.
What a good dental record contains
- A current medical history, updated at appropriate intervals.
- Examination findings, diagnosis and the treatment plan.
- The treatment options discussed — including no treatment and referral — with their risks, benefits and costs.
- Evidence of consent (verbal or written) or refusal.
- Treatment provided, materials used, and any complications.
- Radiographs, photographs and correspondence, retained and identifiable.
Contemporaneous, accurate, unaltered
Make entries at or close to the time of care; late reconstruction is far weaker evidence. Never alter a record after a complaint arises — corrections should be made transparently, dated, and never obscure the original. Altering records is treated very seriously by the Board and can turn a defensible matter into an indefensible one.
Privacy, retention and access
Dental records are health information and must be stored securely and handled in line with the Australian Privacy Principles. Retention periods are set by state and territory law — generally at least seven years from the last entry for adults, and for children until they reach a specified age — and patients have a right to access their records. If you close or sell a practice, records must be transferred or handled appropriately.
Records and complaints
When a concern arises, your records are the backbone of your response, letting you show exactly what was examined, discussed, consented to and done. Our guides to informed consent and Dental Board complaints complete the picture.
Related CPD courses
Build the documentation habits this article describes with CPD for Australian practitioners:
CPD courseDocumentation for Healthcare Professionals CPD courseConfidentiality in Healthcare Practice CPD courseProfessionalism and Professional Standards for Dentists and Dental PractitionersContinue the Dental Board series
Complaints Explained Informed Consent in Australian Dental PracticeFrequently asked questions
What must a dental record include?
A current medical history, examination findings, diagnosis, the treatment options discussed with their risks and costs, evidence of consent or refusal, the treatment provided, and any radiographs or correspondence.
How long must dental records be kept?
Retention is set by state and territory law — generally at least seven years from the last entry for adults, and for children usually until they reach a specified age.
Can I correct a dental record?
Yes, but transparently — date the correction and never obscure or delete the original. Altering records after a complaint is treated very seriously.
Do patients have a right to their dental records?
Yes. Under privacy law patients can generally access the health information held about them, subject to limited exceptions.
Why do records matter in a complaint?
Contemporaneous notes let you show exactly what was examined, discussed, consented to and done; if a discussion is not recorded, the patient's account may be accepted over yours.
This article is general information for education and CPD purposes. It is not legal advice and does not create a practitioner–adviser relationship. If you have received a notification, seek advice from your professional indemnity insurer, your union or professional association, or an independent lawyer experienced in health practitioner regulation. Healthcare Ethics Courses is an independent education provider and is not affiliated with, endorsed by, or acting on behalf of Ahpra or any National Board; regulator names are used for reference only.