01
Reason for attendance
Mandatory
▼
Reason
e.g. "New patient examination. Patient self-registered — no specific complaint at presentation."
02
Medical history (MHQ)
Mandatory
▼
MHQ status
e.g. "MHQ completed and signed by patient. Reviewed — no significant medical history, no regular medications, NKDA, no previous adverse reactions to LA."
Significant findings (if any)
e.g. "Warfarin — INR not checked today. Advised patient to contact GP prior to any extractions."
03
Soft tissue exam & oral cancer screening
Mandatory
▼
STE findings
e.g. "STE: no mucosal lesions, no lymphadenopathy, no TMJ signs on palpation, no facial asymmetry. OCS performed — no suspicious lesions, erythroplakia, or leukoplakia noted."
Suspicious findings (if present)
e.g. "White patch left lateral tongue — 5 mm, non-removable, asymptomatic, 3-week duration. Urgently referred. Patient informed."
04
BPE & periodontal assessment
Mandatory
▼
BPE scores by sextant
e.g. "BPE: 2|2|3 / 2|2|2. Highest score UL sextant — BPE 3."
Periodontal risk
e.g. "Periodontal risk: low-moderate. BPE 3 single sextant, localised BOP, non-smoker, well-controlled T2DM."
Full periodontal chart (if BPE ≥ 3)
e.g. "Full 6-point charting completed — see chart. Pockets ≤3 mm throughout, UR6 MB: 4 mm with BOP."
05
Clinical findings & dental charting
Mandatory
▼
All clinical findings
e.g. "Base charting complete — see chart. Caries: UR4 MOD (radiographically to dentine), LR6 marginal breakdown existing MOD amalgam. No periapical pathology. Occlusion: Class I. No significant wear or TMD signs."
Caries risk
e.g. "Moderate. Previous caries, frequent sugar intake. OH instruction given."
Soft tissue / OC risk
e.g. "Low. Non-smoker, alcohol within guidelines. Lifestyle advice given."
06
Radiographs
Conditional
▼
Films taken / not taken
e.g. "PA UR4 and LR6 taken." — or — "No radiographs taken — previous records requested from last practice."
Justification
e.g. "Caries diagnosis and restoration planning UR4, LR6."
Quality grading
e.g. "UR4 — diagnostic. LR6 — diagnostic. No cone cut."
Clinical report (findings per film)
e.g. "UR4: caries mesial, mid-dentine, no periapical pathology. LR6: marginal breakdown confirmed, no periapical pathology."
07
Treatment plan, consent & costs
Mandatory
▼
Treatment proposed
e.g. "UR4 MOD composite, LR6 MOD amalgam replacement — within therapist scope. LL7: heavily restored, asymptomatic — monitor."
Options discussed & consent obtained
e.g. "NHS Band 2 (£97.10) vs private (£120/tooth). Patient accepted NHS Band 2. Charge explained and accepted. Signed NHS estimate and FP17DC obtained."
Treatment patient declined
e.g. "LL7: patient informed of risk of future RCT or extraction. Asymptomatic. Patient declining treatment at this time. Documented."
08
Recall interval & close
Mandatory
▼
Recall interval (NICE-aligned)
e.g. "6 months (NICE — moderate caries risk, BPE 3)."
Appointments booked / next steps
e.g. "UR4 composite, LR6 replacement, recall booked 6 months."
Referrals made
e.g. "Referred oral medicine — white patch left lateral tongue, 3-week duration. Patient informed. Referral letter sent."
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