The Routine Recall Exam Notes Template UK Dentists Use
A routine recall exam notes template captures the focused re-assessment carried out at a continuing patient's scheduled review — updating medical history, BPE, soft tissue / oral cancer screen, charting changes, radiograph justification, risk reassessment, and recall interval — that satisfies GDC Principle 4 and CGDent/FGDP Clinical Examination and Record-Keeping (3rd ed).
Recall exams are the most common appointment type — and the easiest to under-document. Below is the focused template UK dentists paste into their PMS for a continuing patient: update what's changed, confirm what hasn't, finish in 60 seconds with a defensible record.
Download the free Routine Recall Exam template — plain text, GDC/FGDP(UK)-aligned.
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 IRMER justification was considered.
- Oral cancer screen on its own line — never let an audit-trail gap creep in over years of recalls.
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 — risk-based interval (3-24 months) must be documented with rationale at every recall.
- IRMER 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 mistakes UK dentists make
- 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 expects at least annual BPE.
- 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 — the single most-cited deficiency in MDDUS / Dental Protection review of recall notes.
Frequently asked questions
How is a recall exam different from a new patient exam?
A new patient exam captures the full baseline — comprehensive medical history, dental history, oral cancer baseline, baseline charting. A recall exam updates the variable elements (changes since, BPE, charting deltas, radiographs per interval, risk reassessment). You don't need to re-record what hasn't changed, but you must document that you reviewed it.
Do I need BPE at every recall?
BSP recommends BPE at least annually for adults and at every periodontal recall (3-6 months) for patients on a perio recall. The template prompts BPE every recall so the trend is defensible over time.
How do I justify NOT taking radiographs at this recall?
IRMER 2017 requires clinical justification before taking a radiograph — equally, you can justify NOT taking one. "Last BWs <12 months, asymptomatic, low caries risk — radiographs not indicated this visit per FGDP selection criteria" is a defensible note.
What recall interval should I use?
NICE CG19 requires risk-based intervals: low-risk adults 12-24 months, moderate 6-9 months, high 3 months. Children at increased caries risk every 3-6 months. The template prompts you to record both the interval and the rationale (which risk drove the choice).
Do I need to repeat the oral cancer screen at every recall?
Yes — CQC Key Line of Enquiry W3 expects evidence of oral cancer risk assessment at every recall. The dedicated line makes this auditable. Skipping it because "everything looked fine last time" is the single most-cited deficiency in indemnity reviews.
Can I use the same template for NHS and private recalls?
Yes — the clinical assessment is identical. NHS-specific elements (band, UDA) live in your PMS billing fields, not the clinical note. Private fee codes likewise.