Dental Record Audit Template

Use this Dental Record Keeping Audit Template to review patient records, ensure compliance, identify gaps and improve documentation accuracy in clinics.

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Dental Record Audit Template



Patient Identification & Administrative Accuracy

1. The patient’s full name, date of birth, and current address are correctly recorded and verified.


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2. A unique patient identifier (e.g., NHS number or system ID) is clearly visible on every page or digital entry.


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3. Emergency contact details and the name of the patient’s General Practitioner (GP) are present and up to date.


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4. All entries are dated, and the identity of the clinician (and dental nurse, where applicable) is clearly recorded.


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Medical & Dental History

1. A comprehensive medical history, signed and dated by the patient, is present and has been updated within the last 6–12 months.


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2. All known allergies (especially to Latex, Penicillin, or local anesthetics) are highlighted prominently in a "Warning" or "Alert" field.


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3. Current medications, including dosage and frequency, are accurately listed and reviewed at every visit.


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4. Smoking status and alcohol consumption are recorded for all adult patients as part of the social history.


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Clinical Examination & Assessment

1. The "Reason for Attendance" (chief complaint) is recorded in the patient’s own words.


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2. A full "Baseline Charting" of the dentition (missing teeth, existing restorations, and decay) is present and accurate.


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3. Soft tissue examinations, including a screening for oral cancer, are documented for every check-up.


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4. Periodontal health is recorded using the Basic Periodontal Examination (BPE) or 6-point pocket charting as appropriate.


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Radiography & Diagnostic Tests

1. The clinical justification for taking every radiograph is clearly documented in the notes.


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2. A formal report (finding) for every X-ray is recorded, covering all teeth and structures visible on the image.


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3. The quality grade of the radiograph (Grade 1, 2, or 3) is recorded alongside the report.


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4. All other diagnostic tests (e.g., sensibility testing or study models) have their results clearly documented.


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Treatment Planning & Informed Consent

1. A clear "Diagnosis" or "Differential Diagnosis" is recorded for any identified pathology.


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2. All treatment options discussed (including the option of no treatment) are documented.


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3. A written treatment plan, including the estimated costs, has been provided to the patient and a copy is retained in the record.


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4. Evidence of informed consent (verbal or signed) is recorded, demonstrating that the patient understands the risks, benefits, and costs.


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Clinical Notes & Post-Operative Care

1. Clinical notes are contemporaneous (written at the time of treatment or immediately after).


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2. The specific brand and batch number of local anesthetics, including the dose and expiry date, are recorded.


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3. For surgical procedures, the type of suture used and any post-operative instructions given to the patient are documented.


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4. Any "Adverse Incidents" or complications during treatment are recorded in detail, along with the action taken.


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Security, Legibility & Professionalism

1. All entries are legible (if handwritten) and written in clear, professional language without offensive abbreviations.


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2. Any corrections to the record are made by a single line through the error, signed and dated, without obscuring the original text.


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3. The records are stored securely in compliance with Data Protection/GDPR regulations.


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4. Access to the records is restricted to authorized personnel, with an audit trail for digital entries.


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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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