Skip Ribbon Commands
Skip to main content

Dental Recordkeeping Guidelines

Good dental recordkeeping is critical to the practice of dentistry. It ensures continuity of care for patients and may help to reduce the likelihood of a complaint. The Dental Recordkeeping Guidelines contain the requirements for dental recordkeeping and the ownership, transfer and retention of dental records.

Documentation

Dental Recordkeeping Guidelines

Sample charts/forms

Patient Registration
Medical History
Dental History
Diagnosis and Treatment Plan
Treatment Notes

Initial Periodontal Occlusal Examination
Periodontal Chart
Odontogram Existing and Planned Treatment
Lesion Tracking Sheet

Key points

Dentists must now maintain complete patient records as follows:

  • Records for which the most recent entry was created on or after 1  June 2013 must be kept for 16 years from the date of last entry.
  • Records for which the most recent entry was created before 1 June 2013, must be kept for 31 years (the ULP under the former Limitation Act, plus one year for service) from the date of last entry or until 1 June 2029 (whichever comes first).

In addition to clinical records, other records that must be retained include appointment records, lab prescriptions and invoices. Diagnostic or study models are also considered part of the permanent patient record and must be kept for the prescribed period.

Working models do not have to be retained for any specific period of time. A decision to keep working models should be based on the complexity of the case and is left to the judgment of the individual practitioner.

Exceptions: The above guidelines do not apply to minors and person under a disability. In these cases, the limitation periods do not begin running until the person turns 19 or until the disability ends.