Reading List

This list collects UK professional standards and practical guidance on keeping contemporaneous, complete and accurate dental records.

GDC Safe Practitioner Framework and Standards

• GDC - The Safe Practitioner: Dental Nurse
  The Safe Practitioner Framework for dental nurses, including Professionalism learning outcome P 1.1 and behaviour P(B)11.
  https://www.gdc-uk.org/docs/default-source/education-and-cpd/safe-practitioner-framework-2024/eqa-gui-011-spf-dental-nurse.pdf?sfvrsn=2e9b563_11

• GDC - Standards for the Dental Team
  Core professional standards for registered dental professionals covering record keeping, confidentiality, consent, communication and the patient’s interests.
  https://www.gdc-uk.org/standards-guidance/standards-and-guidance/standards-for-the-dental-team

• GDC Standards - Principle 4: Maintain and protect patients' information
  Guidance requiring contemporaneous, complete and accurate patient records and the protection of patient information.
  https://standards.gdc-uk.org/pages/principle4/principle4

Dental Record-Keeping Support

• SDCEP Practice Support Manual - Principles of good record-keeping
  Practice guidance on making records clear, accurate and contemporaneous, and on the principles that support good record keeping.
  https://www.psm.sdcep.org.uk/topics/record-keeping/principles-of-good-record-keeping/

• SDCEP Practice Support Manual - Record keeping
  Topic covering record-keeping processes and the responsibilities of the dental team.
  https://www.psm.sdcep.org.uk/topics/record-keeping/

• College of General Dentistry - Clinical Examination and Record-Keeping
  Guidance on clinical examination and how to record findings and treatment accurately.
  https://cgdent.uk/clinical-examination-and-record-keeping/

Records Management and Governance

• NHS Transformation Directorate - Records Management Code of Practice
  Guidance on managing health and care records in England, including retention, storage and disposal.
  https://transform.england.nhs.uk/information-governance/guidance/records-management-code/

• Information Commissioner's Office - UK GDPR guidance and resources
  Guidance on data protection, including lawful and secure handling of personal information.
  https://ico.org.uk/for-organisations/uk-gdpr-guidance-and-resources/

• CQC - Regulation 17: Good governance
  Guidance on systems and processes to assess, monitor and improve quality and safety, including maintaining accurate records.
  https://www.cqc.org.uk/guidance-regulation/providers/regulations-service-providers-and-managers/health-social-care-act/regulation-17

Consult these sources to support correct, timely record keeping in dental nursing practice.