Periodic Oral Evaluation Note (Recall/Check-up)

Patient: [name, DOB, MRN]

Date/Time: [date and time]

Provider(s): [evaluating dentist; include hygienist if applicable]

Visit Type: Periodic Oral Evaluation (Recall) – Established Patient

Chief Concern & Interval History

Chief concern: [patient's stated concern in own words / Routine recall evaluation; denies concerns]

Medical history update: [Medical history reviewed; no changes since [date] / Medical history reviewed; changes noted: [new diagnoses, medications, or allergies]] (Include medications relevant to dental care: anticoagulants, bisphosphonates, immunosuppressants.)

Social history: [tobacco and alcohol use status, if relevant to oral health risk / none relevant]

Dental interval history: [interval symptoms, oral hygiene changes, care received elsewhere / denies interval symptoms]

Examination

Vitals: [BP, pulse if obtained / not obtained]

Extraoral/TMJ: [head/neck symmetry, lymph nodes, TMJ screening findings / unremarkable]

Intraoral Soft Tissue: [oral cancer screening findings] (If normal: "No suspicious lesions on intraoral/extraoral exam." If abnormal: describe location, size, color, texture, duration, and whether photo taken.)

Periodontal: [screening PSR / comprehensive charting]; [gingival inflammation, bleeding on probing, plaque/calculus level and distribution, pocketing, recession, mobility, peri-implant status if applicable]; Periodontal diagnosis: [periodontal health / gingivitis / periodontitis with stage/grade]

Hard Tissue: [caries findings with tooth/surface specificity; restoration status; cracks/fractures; wear patterns; endo screening findings if relevant]

Radiographs: [type taken]; Indication: [clinical rationale]; Findings: [key findings] (If not taken: "Radiographs not indicated based on clinical exam and risk profile" or "Patient declined—risks discussed.")

Assessment

(List diagnoses in priority order with tooth/site specificity, status, and supporting evidence.)

• [Diagnosis] — Tooth/Site: [location]; Status: [new / ongoing / resolved]; [symptomatic / asymptomatic]; Evidence: [clinical/radiographic findings]
• [Additional diagnoses as needed]
• Caries risk: [low / moderate / high] (Include if it influences care decisions.)

Plan

Treatment by problem:

• [Diagnosis]: [Tooth/Site] — Treatment: [proposed procedure]; Patient decision: [accepted / declined / deferred]; Timing: [today / next visit / schedule within timeframe] (If declined, document risks/benefits/alternatives discussed.)
• [Additional problems as needed]

Preventive: [tailored oral hygiene instructions]; [fluoride recommendation with rationale]; [dietary counseling if indicated]; [prophylaxis / periodontal maintenance with rationale if maintenance]

Follow-up: Recall in [interval] months (Rationale: [risk/findings]); Next visit: [purpose and tooth/sites if applicable]

Referrals: [specialty, reason, urgency] (Omit if none.)

Informed consent/declinations: [summary of significant discussions, consents obtained, or declinations with documentation that risks were discussed]

Provider Signature: [name, credentials] — [date/time]

Supervising Dentist Attestation: [attestation statement, name, credentials, date/time] (Include only if supervision required.)