The IR(ME)R-Compliant Dental Radiograph Report Template

Failing to record a clinical evaluation of a radiograph breaches IR(ME)R 2017 reg 12(9) — exposing patients to ionising radiation without recording the diagnostic outcome. Below is a template for UK clinicians to paste into their PMS for every radiograph exposure.

Why this radiograph report template wins

• IR(ME)R 2017 justification recorded explicitly — the legal precondition for exposure, and an easily missed element.
• Quality grade (A/N) per the 2020 Guidance Notes (PHE/FGDP(UK)) — repeat radiograph audit relies on this.
• Structured report sections — never leave findings ambiguous. Crowns / roots / periapical / bone / other — covers every diagnostic question.
• Reporter explicitly named — for OPG and CBCT often reported by a separate clinician; the template makes attribution clear.
• CBCT dose line — dose reference level (DRL) compliance is a key CBCT audit item.

The template (paste into your PMS notes field)

Paste the radiograph report template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

RADIOGRAPH TYPE: [PA / BW / Occlusal / OPG / Cephalometric / CBCT]
PROJECTION / SITE: [Tooth / sextant / region]

JUSTIFICATION (IR(ME)R 2017): [Specific clinical question — e.g. "Caries assessment, 18-month interval, asymptomatic" / "Periapical status pre-RCT" / "Endodontic working length"]
Alternative imaging considered: [Periapical sufficient / CBCT not justified — dose vs benefit]

QUALITY GRADE: [A — acceptable / N — not acceptable, with reason; record why if an N image is not retaken]
Quality issues (if N): [Positioning / exposure / movement / processing]

REPORT (structured findings):
- Crowns of teeth: [Caries — depth, surface, FDI / restorations / no abnormality]
- Roots: [Length / curvature / resorption / fracture]
- Periapical: [Lamina dura intact / widened PDL / periapical radiolucency — size]
- Bone: [Levels — generalised loss % / localised loss / sclerosis / radiolucency]
- Other structures: [Sinuses / IAN canal / mental foramen / TMJ / pathology — incidental findings]

INTERPRETATION / DIAGNOSIS LINKED TO CLINIC:

REPORTING CLINICIAN: [Self — same clinician as referrer / clinical lead reporter for OPG / specialist for CBCT]
REPORT DATE: [Same day if at exposure / specify if reported later]

DOSE NOTES (CBCT only): [DRL — within acceptable limits / dose to patient documented]

REFERRER (if different from reporter):
ACTION TAKEN: [Treatment plan informed / specialist referral / repeat radiograph in __ months]

Try the radiograph report note in the live demo → No account needed.

What good looks like — a worked example

The same radiograph report template, completed for a realistic case.

RADIOGRAPH TYPE: Posterior bitewings (R + L)
PROJECTION / SITE: Posterior teeth, both sides

JUSTIFICATION (IR(ME)R 2017): Caries assessment at routine recall. Previous BWs 18 months ago. Moderate caries risk patient — interval per FGDP selection criteria. Patient asymptomatic.
Alternative imaging considered: BWs are the indicated view for interproximal caries assessment.

QUALITY GRADE: A (acceptable — both films diagnostic, all contacts open, full coverage of crowns to alveolar bone crest)
Quality issues: None.

REPORT (structured findings):
- Crowns of teeth: UR6 — distal restoration, no 2° caries. UL6 — sound. UR5 — early enamel-only mesial caries, no dentine penetration. UL5 — sound. UL4 — DO composite, margins intact. Lower posteriors all sound.
- Roots: Not assessed (BW projection).
- Periapical: Not fully visualised (BW projection).
- Bone: Alveolar crests at CEJ generally. Slight horizontal bone loss LL sextant (~10% root length). UR and UL stable.
- Other structures: Maxillary sinus floor visible UR6 region — clear. No incidental findings.

INTERPRETATION / DIAGNOSIS LINKED TO CLINIC: UR5 enamel-only mesial caries — monitor + prevention (no operative intervention needed at this stage). All other restorations stable. Bone loss LL sextant consistent with previous BPE 3 — supportive periodontal care continuing.

REPORTING CLINICIAN: Self (referrer and reporter the same).
REPORT DATE: Today, same appointment.

ACTION TAKEN: Monitor UR5 with photographs (taken today). Reinforce prevention. Recall 9 months (caries M, perio L).

Compliance: the medico-legal angle

• IR(ME)R 2017 reg 11 — each exposure justified and authorised before it is taken. The justification line satisfies this.
• IR(ME)R 2017 reg 12(9) — a clinical evaluation of every exposure must be recorded. Structured report + interpretation lines.
• Quality grading — 2020 Guidance Notes (PHE/FGDP(UK)) and your QA programme; IRR 2017 covers equipment and dose, not image grading.
• CGDent/FGDP Selection Criteria for Dental Radiography (2018) — when to take what radiograph. The template assumes justification per this guidance.
• GDC Principle 4 — contemporaneous, complete record. Failing to record a clinical evaluation breaches IR(ME)R 2017 reg 12(9).

Common documentation mistakes

• Taking a radiograph and not writing a report — failing to record a clinical evaluation breaches IR(ME)R 2017 reg 12(9).
• Justification reading "routine" or "ortho purpose" — needs a SPECIFIC clinical question (caries assessment / WL / periapical status).
• No A/N quality grade recorded — audit can't track repeat rates without it.
• CBCT taken without justifying the dose vs an alternative 2D view — IRR 2017 ALARP principle requires this.
• Reporter same as referrer not stated for OPG/CBCT — leaves attribution ambiguous if a finding is missed.

Sources

• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
• CGDent: Selection Criteria for Dental Radiography (3rd edition) (accessed 18 October 2026)
• The Ionising Radiation (Medical Exposure) Regulations 2017 (SI 2017/1322) (accessed 18 October 2026)

Frequently asked questions

Guides that cover this

• IR(ME)R 2017 in Dental Notes: Radiograph Justification and Clinical Evaluation

Patient leaflets for this treatment

• Your Guide to Dental X-rays

Related dental note templates

Browse the full set of free dental notes templates.