In short
A record keeping CPD course is worth taking when a complaint or GDC concern turns on what your notes show, because GDC standard 4.1 asks for records that are “contemporaneous, complete and accurate”, and the GDC reads them early in an investigation. Our Probity & Ethics GDC record keeping course, Professionalism in Documentation for Healthcare Professionals, is a CPD course on clinical notes, correcting errors and records in regulatory processes: £79 (£50 with Bulk Buy 10), 2 CPD hours, with a dated certificate on completion. With a reflection and an audit of your own notes, it is evidence of remediation for the case examiners, and the same CPD course counts as verifiable CPD.
Your notes are under question?
A complaint or GDC letter where the treatment plan, consent note or medical history is missing, late or unclear.
Improving your records for CPD?
You want verifiable hours on documentation, with a dated certificate.
What dental professionals should know about GDC record keeping
The GDC’s record keeping standards sit in Principle 4, “Maintain and protect patients’ information”. Standard 4.1 reads “You must make and keep contemporaneous, complete and accurate patient records”. The guidance beneath it asks for:
- an up-to-date medical history, and complete and accurate records each time you treat a patient (4.1.1);
- notes that are “clear, legible, accurate, and can be readily understood by others”, with the name or initials of the treating clinician (4.1.4);
- amendments that are clearly marked up and dated (4.1.5);
- patients’ access to their records, which they have a right to though they do not own them (4.4);
- information kept secure, whether on paper or electronic (4.5).
Standard 2.3.6 also asks for a written treatment plan with a copy in the notes, and 3.1.2 for consent discussions to be documented, so a gap in the notes can become a question about consent or cost.
When does a dental professional need a record keeping course?
- A complaint where your notes do not show what you say you discussed with the patient.
- A GDC letter that quotes your own records back to you.
- A practice audit that found missing medical history updates or treatment plans not filed.
- An entry written after the event that was not marked as late.
- Records shared, sent or stored without proper security.
The standards apply to the whole dental team, not only dentists.
How the GDC uses your records in an investigation
At the investigation stage the GDC may collect patient records and clinical advice. For streamlined clinical cases about a single patient, its first inquiries go no further than requesting the clinical records, which a Clinical Dental Adviser reviews before the GDC closes the case or refers it to the case examiners. Your notes may be the main evidence read.
Never alter an existing entry once a concern is raised; any addition must be marked and dated (4.1.5). If the case is referred, the case examiners can agree undertakings with you, and the GDC’s practice committee guidance notes that conditions can require a registrant to “provide reports, logs, and/or audits to the GDC” (paragraph 264). An audit of your own records, done now, is evidence of a kind the GDC already uses.
How each regulator treats records is compared in our record keeping course guide.
What the GDC record keeping course covers
Eight sections: honest, objective and accountable records; note-keeping technique, recording patient interactions and treatment, and correcting an error or making a late entry; non-clinical documents; why records matter in an investigation and how they serve as evidence of conduct and remediation; what the regulators require; what a breach looks like and the practical steps to remediate; and a post-course assessment.
Building evidence beside the course
- Finish the course and keep the dated certificate.
- Audit a sample of your own recent records against standards 4.1.1 and 4.1.4, and write down what you found.
- Change one thing in your template, such as the medical history prompt or the treatment plan copy, and date the change.
- Repeat the audit after a few weeks and record the result.
- Write a reflection linking the concern to Principle 4 and to the audit results.
The practice committee guidance asks committees to satisfy themselves that learning “addresses the concerns raised” (paragraph 246). A before-and-after audit shows that it did.
When a different course fits better
- The notes were complete, but the patient was not told when something went wrong: Duty of Candour in Healthcare Practice.
- The gap is in what the patient agreed to, not in how it was written down: Privacy, Consent and Chaperone in Healthcare Practice.
Record keeping as GDC verifiable CPD
Link the course to development outcome C, “Maintenance and development of your knowledge and skills within your field(s) of practice”, or to outcome A if the records gap concerned consent or a complaint. The GDC accepts a certificate, a mapping document or an email from the provider as evidence of verifiable CPD. The hours for each registered title are in our guide to CPD courses for dentists and dental nurses.
Please note
This guide is general information, not legal advice. No course decides the outcome of a case. Speak to your defence organisation, indemnity provider or union before you send anything to the GDC.
Our GDC record keeping course, for a concern and for CPD
For the whole dental team
Professionalism in Documentation for Healthcare Professionals
Clinical and non-clinical records, correcting errors and late entries, and records as evidence in a regulatory process, with practical remediation steps. Probity & Ethics is CPD certified and accredited by The CPD Certification Service (provider no. 13197).
- £79 (£50 with Bulk Buy 10)
- 2 CPD hours
- Certificate on completion
Courses that sit beside it
Bulk Buy covers the £79 courses: 3 for £200, 5 for £300, 10 for £500. Not sure what to take? Book a free 15-minute call or see which course do I need.
This guide is part of our Professional Misconduct hub, which brings together every Probity & Ethics guide and course on the subject.
The CPD courses linked from this guide, Professionalism in Documentation for Healthcare Professionals, Duty of Candour in Healthcare Practice, Privacy, Consent and Chaperone in Healthcare Practice and Module on Reflection, are by Probity & Ethics, written by Dr Shehzad Iqbal, CPD certified and accredited by The CPD Certification Service (provider no. 13197) and offered since 2020.
Questions and answers
Does a record keeping course count as verifiable CPD for the GDC?
It can. Keep the certificate and link the course to a development outcome in your personal development plan. Probity & Ethics is CPD certified and accredited by The CPD Certification Service (provider no. 13197).
Will the GDC look at my patient records?
Yes, if it investigates. For single-patient clinical cases its first inquiries are limited to requesting the clinical records, which a Clinical Dental Adviser reviews.
What does the GDC expect of records kept by dental professionals?
GDC standard 4.1 asks dental professionals to make and keep contemporaneous, complete and accurate patient records, with an up-to-date medical history and notes that others can readily understand.
Can I add to my notes after a complaint?
Do not alter what is already there. If you need to add something, the GDC’s guidance at 4.1.5 says changes must be clearly marked up and dated. Speak to your indemnifier first.
Do dental nurses need a record keeping course too?
The Standards for the Dental Team apply to every registered title, including dental nurses. A dental nurse whose records are questioned can use the same course, and it counts towards the 50 hours of CPD dental nurses need in each five-year cycle.
Sources
This guide is based on the following GDC pages, read on 5 November 2026.
