Routine Recall Exam Notes Template for UK Dentists

Recall exams are routine and frequent — and easy to under-document. Below is a focused template for UK clinicians to paste into their PMS for a continuing patient: update what's changed, confirm what hasn't, finish with a defensible record.

Why this routine recall exam template wins

• Focused on what changed — no need to re-document an entire history every recall, just the deltas.
• BPE comparison line ("Changes since last") forces an explicit trend statement — defensible against gradual decline that goes unnoticed.
• Risk reassessment grades all four risks (caries / perio / TSL / oral cancer) so changes in risk drive the recall interval.
• Radiograph line accepts both "taken" AND "declined because last BWs <12 months" — proves the IR(ME)R justification was considered.
• Oral cancer screen on its own line — never let an audit-trail gap creep in over years of recalls.

The template (paste into your PMS notes field)

Paste the routine recall exam template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

REASON FOR ATTENDANCE: Routine recall.

MHx: [Updated — changes since last visit / unchanged]
Medications: [Changes only / unchanged]
Allergies: [Confirmed / new]

EXTRA-ORAL: [NAD / TMJ / lymph nodes]
INTRA-ORAL SOFT TISSUE: [All sites examined — NAD / lesions described]
ORAL CANCER SCREEN: Completed — [no suspicious lesions]

PERIODONTAL — BPE:
  UR _   UA _   UL _
  LR _   LA _   LL _
Changes since last BPE: [Stable / improved / worsened — sextant(s)]

CHARTING (changes since last visit):
- New caries: [FDI numbers]
- Restorations status: [Stable / margins to monitor / failed]
- Wear: [BEWE — change since last]

RADIOGRAPHS: [Type — justification (IR(ME)R) — quality A/N — report / declined because last BWs <12 months]

RISK REASSESSMENT: caries [L/M/H] · perio [L/M/H] · TSL [L/M/H] · oral cancer [L/M/H]

DIAGNOSIS / NEW PROBLEMS:

OPTIONS, RISKS, BENEFITS, ALTERNATIVES DISCUSSED: [Montgomery — for any new treatment / NIL if no new treatment proposed]

TREATMENT PLAN: [No changes / new items added below]
1.
2.

PREVENTION REINFORCED: [OHI / diet / fluoride / smoking]

RECALL: [3/6/9/12 months] — rationale: [NICE CG19 risk-based]

Try the routine recall exam note in the live demo → No account needed.

What good looks like — a worked example

The same routine recall exam template, completed for a realistic case.

REASON FOR ATTENDANCE: Routine 6-month recall.

MHx: Updated — no changes. Medications unchanged (amlodipine 5mg OD). Penicillin allergy confirmed.

EXTRA-ORAL: NAD. TMJ — no click, MO normal.
INTRA-ORAL SOFT TISSUE: All sites examined — NAD.
ORAL CANCER SCREEN: Completed — no suspicious lesions.

PERIODONTAL — BPE:
  UR 2   UA 1   UL 2
  LR 2   LA 1   LL 2
Changes since last BPE: LL improved from 3 → 2 following hygiene programme. Stable.

CHARTING (changes since last visit):
- New caries: Nil
- Restorations status: All stable. LR6 MO composite margins — staining noted previously, now polished — to monitor
- Wear: BEWE 0 generalised, stable

RADIOGRAPHS: Posterior BWs taken (R+L). Justification — caries assessment, 12-month interval per NICE CG19. Quality A. Report: No frank interproximal caries. No 2° caries around restorations. Bone levels stable LL sextant.

RISK REASSESSMENT: caries L (improved from M) · perio L (improved from M) · TSL L · oral cancer L

DIAGNOSIS / NEW PROBLEMS: None. Stable.

OPTIONS, RISKS, BENEFITS, ALTERNATIVES DISCUSSED: N/A — no new treatment proposed.

TREATMENT PLAN: No changes. LR6 margins to monitor next recall.

PREVENTION REINFORCED: OHI maintained (modified Bass + TePe). Fluoride 22,600 ppm applied today.

RECALL: 9 months. Caries L / perio L — NICE CG19. Hygiene at 4 months.

Compliance: the medico-legal angle

• CGDent/FGDP Clinical Examination and Record-Keeping 3rd ed — recall exam requires same elements as a baseline exam updated for change.
• NICE CG19 (Dental Recall): choose each patient's recall interval from their risk assessment — 3 to 24 months for adults, 3 to 12 months for under-18s — and record it with the reason.
• IR(ME)R 2017 — justification, quality, and report for every radiograph; explicit "declined because last BWs <12 months" is itself a defensible justification statement.
• GDC Standards Principle 4 — contemporaneous, complete, accurate. A focused recall note that shows trend changes meets this; a copy-paste "all NAD" does not.

Common documentation mistakes

• Copy-pasting "all NAD, recall 6/12" — no risk reassessment, no oral cancer screen documented, no medical history update. Indefensible.
• No BPE recorded because "patient was here 6 months ago" — BSP 2019 expects a BPE at every routine examination for codes 0–2.
• Recall interval defaults to 6 months for every patient — NICE CG19 requires risk-based justification.
• No "changes since last visit" line — fails to capture the trend (e.g. tooth wear progressing).
• Skipping oral cancer screen at recall — a frequent gap in recall notes.

Sources

• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
• CGDent: Clinical Examination and Record-Keeping, Good Practice Guidelines (3rd edition) (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)
• Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015, UKSC 11) (accessed 18 October 2026)
• NICE CG19: Dental checks: intervals between oral health reviews (October 2004) (accessed 18 October 2026)
• BSP: The Basic Periodontal Examination (BPE), 2019 (accessed 18 October 2026)

Frequently asked questions

Guides that cover this

• Dental Notation Systems: FDI vs Palmer vs Universal (with Charts)
• UK Dental Record-Keeping: Dento-Legal Standards & What Your Notes Must Contain
• NICE CG19 Recall Intervals: What to Record in Dental Notes
• IR(ME)R 2017 in Dental Notes: Radiograph Justification and Clinical Evaluation

Patient leaflets for this treatment

• Understanding Tooth Decay
• Understanding Gum Disease
• Understanding Sensitive Teeth

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