What a dentist must record in your clinical notes is set by the Code of conduct: accurate, up-to-date, factual, objective and legible records that another health practitioner could understand. That sounds like a rule written for dentists, and it is. But the reason it matters is almost entirely about you, later. Notes are what a new dentist reads, what an insurer asks for, what a complaint body examines, and what stands behind a claim. This page covers both halves.
Key takeaways
- The Code of conduct requires records that report clinical history, findings, investigations, information given to you, medication and management, in a form other practitioners can understand.
- Records must be made at the time or as soon as possible afterwards, and must show respect for patients with no demeaning or derogatory remarks.
- Each entry should identify the date and time of the service and who provided it.
- Informed consent and financial consent are both things the record is expected to document.
- You have a right to access the information a practice holds about you, including reports it received from other practitioners.
- Retention periods are set state by state, so the New South Wales private-sector position is not a national rule.
The rules that apply to dental records in New South Wales
The Dental Board of Australia retired its separate guidelines on dental records and now points practitioners to the shared Code of conduct, supported by its fact sheet on maintaining patient health records and a self-reflective tool. So the Code is the governing document, not a dental-specific guideline.
Privacy law sits alongside it. For private practices, the Privacy Act and the OAIC's Guide to health privacy govern access, correction and disclosure. In New South Wales, the Health Records and Information Privacy Act adds state-level obligations for health information, including retention.
What has to be in the record
The Code of conduct's health records section requires accurate, up-to-date, factual, objective and legible records that report the relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management, in a form that can be understood by other health practitioners.
It also requires that records are held securely and are not subject to unauthorised access, including electronic records; that they show respect for patients and do not include demeaning or derogatory remarks; that they are sufficient to facilitate continuity of care; and that they are made at the time of events or as soon as possible afterwards.
Ahpra's summary of obligations for managing health records adds practical detail. Records must be objective and non-judgemental, and must not include remarks that could be interpreted as prejudiced, demeaning, derogatory, discriminatory, racist or culturally unsafe. Each record should clearly identify the date and time the service was provided, who provided it, and where relevant, where it was provided. Documenting informed consent for treatment, examinations and services is described as important, with written consent potentially needed for higher-risk procedures. Billing information must be kept accurate and up to date. History taking should include relevant psychological, social and cultural aspects, and should include checking available electronic records such as My Health Record.
On consent, the Code requires practitioners to document consent appropriately, including considering the need for written consent for procedures that are higher risk or may result in serious injury or death, and says informed consent must include information on material risks and expected outcomes. Separately, the Code requires financial consent covering the costs of all required services, which we cover in informed financial consent and getting a written quote.
What belongs in a dental record, and why it matters later
| What is recorded | Why it is recorded | Where it matters later |
|---|---|---|
| Clinical history and medical history | Safety, and understanding the context of your care | A new practitioner knows your medications, allergies and conditions without starting again |
| Examination and clinical findings | The factual basis for any diagnosis | Shows what was present at a point in time, which matters if something is later said to have changed |
| Radiographs, scans and other investigations | Objective evidence supporting findings | Transfers to a new practice and avoids repeat imaging |
| Diagnosis and treatment plan with stages | Continuity, and clarity about what was proposed | Supports quotes, insurance queries and any staged funding application |
| Information given to you and material risks discussed | Informed consent requires it | Central to any question about what you were told before agreeing |
| Informed consent, including written consent for higher-risk procedures | The Code requires consent to be documented appropriately | The record of the conversation, not just the signature, is what gets examined |
| Financial consent and what was quoted | The Code requires costs of all required services to be discussed and agreed | Resolves fee disputes quickly, and supports any itemised quote |
| Treatment provided, with date, time and who provided it | Ahpra's summary expects each record to identify these | Establishes a timeline, which is what claims and complaints turn on |
| Correspondence and specialist reports received | Part of the information the practice holds about you | You can access it even though the practice did not write it |
Why the notes matter to you, later
This is the part patients almost never think about until it is urgent.
When you change dentists
A new practitioner reading your record wants to know what was found, what was done, when, and what the plan was. Records that are sufficient to facilitate continuity of care are a Code requirement precisely because this handover happens constantly. Good notes save you a repeat examination, sometimes repeat imaging, and the frustration of explaining a history you half remember. We cover the mechanics in changing dentists and transferring records and x-rays.
When you make an insurance or benefits claim
Claims are decided on documentation. A staged treatment plan, an itemised account, dated treatment entries and clear findings are what a fund or an assessor works from. Where a funding pathway requires evidence, the standard is set by whoever is assessing, and the record either meets it or it does not. I am not going to advise on how to run a claim, because that is specific to the claim and the policy. The general point stands: the notes are the evidence, and they are written long before anyone knows a claim is coming.
When something happened at work or in an accident
If a tooth was damaged in an incident, the contemporaneous record of the damage matters more than anything said afterwards. A record made at the time, with a date and a description of the findings, is a very different thing from a recollection reconstructed months later. That is true for a workers compensation matter, a motor accident, or any injury claim. Our guide on dental injury at work and workers compensation in NSW covers the first steps, and the record made at the first appointment is part of why those first steps matter.
When you make a complaint, or someone questions the care
Ahpra states that good records contribute to the safety and continuity of health care and help when practitioners need to provide information to involved parties, such as other health practitioners, Medicare or National Boards. From your side, a complaint about care is examined largely through the record. If you are considering that route, our page on how to make a complaint about dental treatment in NSW sets out the pathways. I am not going to predict how any body would decide a matter, because that depends on the facts.
When you want a second opinion
A second opinion is far more useful when the second practitioner can see the first practitioner's findings and images rather than starting from scratch. Requesting your records before the appointment is usually the single most useful thing you can do, and it is covered in when to get a second opinion as an adult.
The point that changes how notes get written
The OAIC makes an observation in its health privacy guidance that deserves more attention than it gets. When a practitioner makes a clinical record of an interaction with a patient, they should be aware that if the patient requests it, generally they would need to give the patient access to those notes.
The OAIC also states plainly that feeling embarrassed or apprehensive about the patient reading the notes is not a legitimate ground for refusing access. Those two sentences together are the reason the Code's requirement for objective, non-judgemental language is not a formality. Notes are written in the knowledge they may be read by the person they are about.
How long records are kept
Retention is set by state and territory legislation, so there is no single national number, and any page that gives you one without saying which state it means is being loose.
For private sector health service providers in New South Wales, the Health Records and Information Privacy Act sets the retention period. The figures that appear consistently across summaries of that section are seven years from the last occasion a health service was provided, for information collected while the individual was an adult, and until the individual turns 25, for information collected while the individual was under 18. I want to be straight about the sourcing on this one: those figures are widely repeated and consistent across independent summaries, but I could not confirm them against the Information and Privacy Commission's own published fact sheet or the section text, so treat them as unconfirmed and check with the IPC in New South Wales or ask the practice directly.
The age-25 rule, if it is as summarised, is the one parents should know about, because it means records made in childhood are kept well past the point most people expect.
Where records are deleted or disposed of, a provider is expected to keep a record of the individual's name, the period the information covers, and the date of disposal. Where records are transferred, the provider records the recipient's name and address. So there should be a trail even after the file itself has gone.
Public services run on a different regime
If you were seen at a public dental clinic or a public hospital in New South Wales, that record is not governed by the private-sector clock. Public health services are covered by a State Records NSW retention and disposal authority for public health services patient records, together with NSW Health policy directives. The periods vary by record type, and I am not going to publish a number for them because I could not verify the specifics. State Records also notes that keeping records longer than the required minimum could itself create a privacy problem, which is a useful corrective to the assumption that longer is always better.
The practical takeaway for a Melrose Park household: if some of your history sits with a public service and some with private practices, they are two separate requests under two separate regimes.
Getting access, and getting it corrected
The Code requires practitioners to recognise the right of patients to access information in their health records, to facilitate that access, and to promptly facilitate transfer or management of health information when requested by patients or when closing or relocating a practice.
The OAIC adds the mechanics for private practices. A provider should respond within a reasonable period, and in most cases a reasonable period will not exceed 30 calendar days. Access should be given in the manner requested unless that is unreasonable or impracticable. You are entitled to information the provider holds regardless of who authored particular documents or who owns the record, which expressly includes specialist reports the practice received from others. Ten specific grounds allow refusal, and where access is refused the provider must take reasonable steps to give access in another way and must give written notice with reasons and complaint mechanisms.
Charges are permitted but must not be excessive. There is no charge for making a request, flat fees are generally not appropriate, and financial hardship should be considered. I am not publishing a figure or a range, because there is no set amount.
On correction, privacy law provides a route to ask for information to be corrected where it is inaccurate, out of date, incomplete, irrelevant or misleading. In practice, clinical opinions recorded at a point in time are not usually rewritten. What normally happens is that a correction or your statement is added to the record rather than the original being erased. Ask in writing and be specific about what you say is wrong.
If the practice closes or relocates
This is a real anxiety and the Code addresses it directly. Practitioners are required to promptly facilitate the transfer or management, including disposal, of health information in accordance with privacy and health records legislation when requested by patients, or when closing or relocating a practice. If a practice you attended has closed, ask where the records went. There should be an answer.
Frequently asked questions
What should be in your dental records?
The Code of conduct requires clinical history, clinical findings, investigations, the information given to you, medication and other management, recorded accurately and objectively in a form other health practitioners can understand. Ahpra's summary adds the date and time of the service, who provided it, documented informed consent, and accurate billing information.
How long do dentists keep records in Australia?
There is no single national period, because retention is set state by state. For private providers in New South Wales the commonly cited figures are seven years from the last service for adults, and until age 25 for information collected when the person was a child, though I could not confirm those against the Information and Privacy Commission's own published material.
How do I get a copy of my dental records?
Ask the practice in writing and say what you want and where it should go. Under OAIC guidance a provider should respond within a reasonable period, usually not exceeding 30 calendar days, and should give access in the manner you requested unless that is unreasonable or impracticable.
Can I get my dental x-rays sent to a new dentist?
Yes. Radiographs are health information the practice holds, and the Code requires practitioners to promptly facilitate transfer when requested. Copies are what is normally provided, and copies are what a new practice actually needs.
What happens to my dental records if the practice closes?
The Code requires practitioners to promptly facilitate the transfer or management of health information when closing or relocating a practice, in line with privacy and health records legislation. Contact the practice or its former principal and ask where records were transferred.
Can I ask for my dental records to be corrected?
Yes, privacy law provides a correction route where information is inaccurate, out of date, incomplete, irrelevant or misleading. Clinical opinions recorded at the time are usually annotated rather than erased, so expect a correction or your statement to be added to the file.
Who can see my dental records?
The Code treats information as held in confidence unless release is required or authorised by law, or is required to facilitate emergency care. Practices are also required to hold records securely and protect them from unauthorised access, including electronic records.
If you are joining a new practice, bringing your records with you makes the first appointment far more useful than starting from a blank page. The team at Lumi Dental in Melrose Park is open Monday to Saturday and is happy to request them on your behalf. You can see what is currently available on our current offers page, or book a visit when it suits you.
This article is general information only and is not legal advice. It is also not personalised dental advice, because that requires an examination. Legislation, codes and retention rules change and differ between states, so check current sources and get advice about your own situation before acting on anything here.
