{"id":33501,"date":"2026-07-06T15:28:25","date_gmt":"2026-07-06T15:28:25","guid":{"rendered":"https:\/\/healthcareethicscourses.com\/au\/?page_id=33501"},"modified":"2026-07-12T17:57:31","modified_gmt":"2026-07-12T17:57:31","slug":"dental-record-keeping-documentation","status":"publish","type":"page","link":"https:\/\/healthcareethicscourses.com\/au\/dental-record-keeping-documentation\/","title":{"rendered":"Dental Record Keeping &#038; Documentation"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"33501\" class=\"elementor elementor-33501\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1536c4c e-con-full e-flex e-con e-parent\" data-id=\"1536c4c\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-40d0d63 elementor-widget elementor-widget-html\" data-id=\"40d0d63\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<!-- Healthcare Ethics Courses \u2014 Dental Board article \u2014 paste into an Elementor Custom HTML block. 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aria-hidden=\"true\">&rsaquo;<\/li>\r\n      <li><a href=\"\/au\/knowledge-support\/\">Dental Board<\/a><\/li>\r\n      <li class=\"sep\" aria-hidden=\"true\">&rsaquo;<\/li>\r\n      <li aria-current=\"page\">Dental Record Keeping and Documentation: Meeting the Standards<\/li>\r\n    <\/ol>\r\n  <\/nav>\r\n\r\n  <header class=\"head wrap\">\r\n    <h1>Dental Record Keeping and Documentation: Meeting the Standards<\/h1>\r\n    <div class=\"meta\">\r\n      <span>8 min read<\/span>\r\n      <span class=\"dot\" aria-hidden=\"true\">&bull;<\/span>\r\n      <span>Last updated June 2026<\/span>\r\n    <\/div>\r\n    <p class=\"lead\">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.<\/p>\r\n  <\/header>\r\n\r\n  <div class=\"takeaways wrap\">\r\n    <h2>Key takeaways<\/h2>\r\n    <ul>\r\n      <li>The shared <strong>Code of conduct<\/strong> requires accurate, up-to-date, factual, objective and legible dental records.<\/li>\r\n      <li>Record the <strong>treatment options discussed<\/strong> \u2014 including no treatment and referral \u2014 not just the treatment performed.<\/li>\r\n      <li>Make entries contemporaneously; never alter a record after a complaint, and correct transparently.<\/li>\r\n      <li>Dental records are health information \u2014 store them securely under the Australian Privacy Principles.<\/li>\r\n      <li>Retention is set by state and territory law \u2014 generally at least seven years for adults, longer for children.<\/li>\r\n    <\/ul>\r\n  <\/div>\r\n\r\n  <div class=\"wrap\">\r\n    <h2>Why dental records matter<\/h2>\r\n    <p>Clinical records are fundamental to safe dentistry and to defending your practice if it is ever questioned. The shared <em>Code of conduct<\/em> 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 \u2014 if a discussion is not recorded, a patient&#8217;s account may be accepted over the practitioner&#8217;s.<\/p>\r\n\r\n    <h2>What a good dental record contains<\/h2>\r\n    <ul>\r\n      <li>A current medical history, updated at appropriate intervals.<\/li>\r\n      <li>Examination findings, diagnosis and the treatment plan.<\/li>\r\n      <li>The <strong>treatment options discussed<\/strong> \u2014 including no treatment and referral \u2014 with their risks, benefits and costs.<\/li>\r\n      <li>Evidence of consent (verbal or written) or refusal.<\/li>\r\n      <li>Treatment provided, materials used, and any complications.<\/li>\r\n      <li>Radiographs, photographs and correspondence, retained and identifiable.<\/li>\r\n    <\/ul>\r\n    <aside class=\"note\"><p>Recording the treatment options you discussed \u2014 not just the treatment you performed \u2014 is one of the most protective habits in dentistry.<\/p><\/aside>\r\n\r\n    <h2>Contemporaneous, accurate, unaltered<\/h2>\r\n    <p>Make entries at or close to the time of care; late reconstruction is far weaker evidence. Never alter a record after a complaint arises \u2014 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.<\/p>\r\n\r\n    <h2>Privacy, retention and access<\/h2>\r\n    <p>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 \u2014 generally at least seven years from the last entry for adults, and for children until they reach a specified age \u2014 and patients have a right to access their records. If you close or sell a practice, records must be transferred or handled appropriately.<\/p>\r\n\r\n    <h2>Records and complaints<\/h2>\r\n    <p>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 <a href=\"\/au\/knowledge-support\/dental-board\/informed-consent-australian-dental-practice\/\">informed consent<\/a> and <a href=\"\/au\/knowledge-support\/dental-board\/dental-board-complaints-explained\/\">Dental Board complaints<\/a> complete the picture.<\/p>\r\n  <\/div>\r\n\r\n  <section class=\"courses wrap\">\r\n      <h2>Related CPD courses<\/h2>\r\n      <p class=\"intro\">Build the documentation habits this article describes with CPD for Australian practitioners:<\/p>\r\n        <a class=\"course\" href=\"https:\/\/healthcareethicscourses.com\/au\/courses\/documentation-for-healthcare-professionals\/\"><span class=\"course-tag\">CPD course<\/span><span class=\"course-name\">Documentation for Healthcare Professionals<\/span><span class=\"course-arr\"><svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/span><\/a>\r\n        <a class=\"course\" href=\"https:\/\/healthcareethicscourses.com\/au\/courses\/confidentiality-in-healthcare-practice-2\/\"><span class=\"course-tag\">CPD course<\/span><span class=\"course-name\">Confidentiality in Healthcare Practice<\/span><span class=\"course-arr\"><svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/span><\/a>\r\n        <a class=\"course\" href=\"https:\/\/healthcareethicscourses.com\/au\/courses\/professionalism-and-professional-standards-for-dentists-and-dental-practitioners\/\"><span class=\"course-tag\">CPD course<\/span><span class=\"course-name\">Professionalism and Professional Standards for Dentists and Dental Practitioners<\/span><span class=\"course-arr\"><svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/span><\/a>\r\n  <\/section>\r\n\r\n  <section class=\"siblings wrap\">\r\n    <h2>Continue the Dental Board series<\/h2>\r\n        <a class=\"sib\" href=\"https:\/\/healthcareethicscourses.com\/au\/dental-board-complaints-explained\/\">Complaints Explained<svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/a>\r\n        <a class=\"sib\" href=\"https:\/\/healthcareethicscourses.com\/au\/informed-consent-in-australian-dental-practice\/\">Informed Consent in Australian Dental Practice<svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/a>\r\n  <\/section>\r\n\r\n  <section class=\"faq wrap\">\r\n    <h2>Frequently asked questions<\/h2>\r\n      <div class=\"faq-item\"><h3>What must a dental record include?<\/h3><p>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.<\/p><\/div>\r\n      <div class=\"faq-item\"><h3>How long must dental records be kept?<\/h3><p>Retention is set by state and territory law \u2014 generally at least seven years from the last entry for adults, and for children usually until they reach a specified age.<\/p><\/div>\r\n      <div class=\"faq-item\"><h3>Can I correct a dental record?<\/h3><p>Yes, but transparently \u2014 date the correction and never obscure or delete the original. Altering records after a complaint is treated very seriously.<\/p><\/div>\r\n      <div class=\"faq-item\"><h3>Do patients have a right to their dental records?<\/h3><p>Yes. Under privacy law patients can generally access the health information held about them, subject to limited exceptions.<\/p><\/div>\r\n      <div class=\"faq-item\"><h3>Why do records matter in a complaint?<\/h3><p>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.<\/p><\/div>\r\n  <\/section>\r\n\r\n  <div class=\"wrap\">\r\n    <p class=\"disclaimer\">This article is general information for education and CPD purposes. It is not legal advice and does not create a practitioner\u2013adviser 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.<\/p>\r\n  <\/div>\r\n\r\n  <script type=\"application\/ld+json\">\r\n{\r\n  \"@context\": \"https:\/\/schema.org\",\r\n  \"@graph\": [\r\n    {\r\n      \"@type\": \"Article\",\r\n      \"@id\": \"https:\/\/healthcareethicscourses.com\/au\/knowledge-support\/dental-board\/dental-record-keeping-documentation\/#article\",\r\n      \"headline\": \"Dental Record Keeping and Documentation: Meeting the Standards\",\r\n      \"description\": \"Dental record keeping and documentation in Australia - what a good record contains, contemporaneous notes, corrections, and privacy, retention and access rules.\",\r\n      \"inLanguage\": \"en-AU\",\r\n      \"datePublished\": \"2026-07-03\",\r\n      \"dateModified\": \"2026-07-03\",\r\n      \"author\": {\r\n        \"@type\": \"Person\",\r\n        \"name\": \"Dr Shehzad Iqbal\",\r\n        \"jobTitle\": \"Founder, Healthcare Ethics Courses\",\r\n        \"description\": \"MRCS, MRCGP, PG Cert Healthcare Law & Ethics (University of Dundee)\"\r\n      },\r\n      \"publisher\": {\r\n        \"@type\": \"Organization\",\r\n        \"name\": \"Healthcare Ethics Courses\",\r\n        \"url\": \"https:\/\/healthcareethicscourses.com\/\"\r\n      },\r\n      \"mainEntityOfPage\": \"https:\/\/healthcareethicscourses.com\/au\/knowledge-support\/dental-board\/dental-record-keeping-documentation\/\",\r\n      \"about\": [\r\n        {\r\n          \"@type\": \"Thing\",\r\n          \"name\": \"Dental Board of Australia\"\r\n        },\r\n        {\r\n          \"@type\": \"Thing\",\r\n          \"name\": \"Dental regulation in Australia\"\r\n        }\r\n      ]\r\n    },\r\n    {\r\n      \"@type\": \"BreadcrumbList\",\r\n      \"itemListElement\": [\r\n        {\r\n          \"@type\": \"ListItem\",\r\n          \"position\": 1,\r\n          \"name\": \"Home\",\r\n          \"item\": \"https:\/\/healthcareethicscourses.com\/au\/\"\r\n        },\r\n        {\r\n          \"@type\": \"ListItem\",\r\n          \"position\": 2,\r\n          \"name\": \"Knowledge & Support\",\r\n          \"item\": \"https:\/\/healthcareethicscourses.com\/au\/knowledge-support\/\"\r\n        },\r\n        {\r\n          \"@type\": \"ListItem\",\r\n          \"position\": 3,\r\n          \"name\": \"Dental Board\",\r\n          \"item\": \"https:\/\/healthcareethicscourses.com\/au\/knowledge-support\/\"\r\n        },\r\n        {\r\n          \"@type\": \"ListItem\",\r\n          \"position\": 4,\r\n          \"name\": \"Dental Record Keeping and Documentation: Meeting the Standards\"\r\n        }\r\n      ]\r\n    },\r\n    {\r\n      \"@type\": \"FAQPage\",\r\n      \"mainEntity\": [\r\n        {\r\n          \"@type\": \"Question\",\r\n          \"name\": \"What must a dental record include?\",\r\n          \"acceptedAnswer\": {\r\n            \"@type\": \"Answer\",\r\n            \"text\": \"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.\"\r\n          }\r\n        },\r\n        {\r\n          \"@type\": \"Question\",\r\n          \"name\": \"How long must dental records be kept?\",\r\n          \"acceptedAnswer\": {\r\n            \"@type\": \"Answer\",\r\n            \"text\": \"Retention is set by state and territory law \\u2014 generally at least seven years from the last entry for adults, and for children usually until they reach a specified age.\"\r\n          }\r\n        },\r\n        {\r\n          \"@type\": \"Question\",\r\n          \"name\": \"Can I correct a dental record?\",\r\n          \"acceptedAnswer\": {\r\n            \"@type\": \"Answer\",\r\n            \"text\": \"Yes, but transparently \\u2014 date the correction and never obscure or delete the original. 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