Headings
Interval history · Medical history update · Extraoral and intraoral exam · Periodontal findings · Radiographs · Findings by tooth · Treatment plan · Recall interval
When to use it
Use this at routine recall for an established patient whose baseline is already on file. It records only what changed since the last visit and lists findings tooth by tooth, so the next exam can compare quickly. It is the dentist’s exam note, while the hygiene visit note covers the cleaning itself.
Example
Fictional example
Interval history
No problems since last recall. Some cold sensitivity upper right for two months.
Medical history update
Started atorvastatin. No other changes.
Extraoral and intraoral exam
Within normal limits. Mild linea alba bilaterally.
Periodontal findings
Stable. Pockets 2 to 3 mm. Minimal bleeding.
Radiographs
Two bitewings. No new interproximal decay.
Findings by tooth
#3 incipient distal enamel lesion, monitor. #4 buccal abfraction, likely source of sensitivity. #14 amalgam intact.
Treatment plan
Class V composite #4. Prescription-strength fluoride toothpaste in the meantime.
Recall interval
6 months.