How to write dental notes in the UK

The 17 sections of a UK dental note

The order runs the way an appointment does: history, examination, findings, discussion, treatment and plan. Leave a section blank if the appointment didn’t cover it, rather than filling it with stock phrases. The structure follows the College of General Dentistry’s guidance, Clinical Examination and Record-Keeping.

1. 01Chief Complaint

   Why the patient came in, in their own words where possible.

   Sensitivity to cold, upper right, for two weeks.

2. 02History of Presenting Complaint

   Onset, duration, character, triggers, what eases it, and anything already tried.

   Sharp, short-lived pain to cold. No spontaneous or night pain. No swelling.

3. 03Medical History

   Conditions, medicines and allergies, and a record that the history was checked and updated at this visit.

   Medical history checked and updated: no changes. No known drug allergies.

4. 04Social History

   Smoking, alcohol and diet, and anything else that affects risk or treatment.

   Non-smoker. Around 6 units of alcohol a week. Frequent sugary drinks.

5. 05Dental History

   Attendance pattern, previous treatment, anxiety and home care.

   Regular attender, last seen 12 months ago. Brushes twice daily, no interdental cleaning.

6. 06Extraoral Examination

   Face, lymph nodes, muscles and temporomandibular joints.

   No lymphadenopathy. TMJs and muscles of mastication within normal limits.

7. 07Intraoral Soft Tissues

   Mucosa, tongue, floor of mouth and palate, including the oral cancer check.

   Soft tissues healthy. Oral cancer screen: no abnormality detected.

8. 08Periodontal

   BPE scores, plaque and bleeding, and fuller charting where the BPE calls for it.

   BPE 2 1 2 / 2 1 2. Supragingival calculus lower anteriors.

9. 09Hard Tissues / Charting

   Caries, restorations, wear and fractures, by tooth, in UK notation (UR6) or FDI, whichever your practice uses.

   UR6 MO cavitated caries into dentine. UL6 sound.

10. 10Special Tests

    Radiographs with their justification, grading and report, and tests such as sensibility or percussion.

    Two bitewings, justified for caries assessment. Graded and reported: UR6 MO radiolucency into dentine.

11. 11Diagnoses

    Your diagnosis, tooth by tooth. It is a clinical judgement, so an AI scribe should record it only when you say it.

    Dentine caries UR6.

12. 12Treatment Options Discussed

    Every reasonable option, including doing nothing.

    Composite restoration, amalgam restoration, or monitor.

13. 13Risks & Benefits

    What was explained about each option, including the risk of not treating.

    Post-operative sensitivity explained. Caries likely to progress if untreated.

14. 14Consent

    What the patient chose, that costs were explained, and how consent was given.

    Patient chose composite UR6. Costs explained. Verbal consent given.

15. 15Treatment Delivered Today

    What was done: anaesthetic, isolation, materials and anything unexpected.

    Scale and polish. Oral hygiene instruction given.

16. 16Advice

    Home care, diet, fluoride and post-operative instructions.

    Interdental brushes advised. Reduce sugary drinks between meals.

17. 17Plan & Recall

    The next appointment and the recall interval, set by the patient’s risk.

    Composite UR6 next visit. Recall in 6 months.

Example lines are illustrative. Recall intervals should follow the patient’s risk, in line with NICE guideline CG19.

A worked example

Here is the same recall examination as one complete note, the way it would sit in the record. The patient is made up.

See a note like this written by Squte, step by step →

What changed in 2026

NHS England’s standard operating protocols

In August 2026 NHS England published guidance on concise clinical record keeping, with example SOPs for four routine procedures: a non-surgical extraction, first-time root canal treatment, a crown or indirect onlay, and an anterior composite. A team agrees its own bank of SOPs, and the note references the one followed. Details specific to the visit, such as the amount of local anaesthetic, are still written down. NHS England says SOPs should not constrain clinical freedom and need regular review dates (NHS England).

The GDC calls SOP referencing “an option for use, rather than a regulatory requirement”, and says narrative records are still needed for assessments, treatment planning and consent (GDC blog, 12 August 2026).

The GDC’s proposed Framework for Professionalism

The GDC has consulted on replacing the Standards for the Dental Team with a Framework for Professionalism built on four core principles, after criticism that the current standards are too prescriptive (Dentistry.co.uk). Nothing changes until a new framework is approved, so Standard 4.1 still applies: make and keep contemporaneous, complete and accurate patient records.

The MHRA’s guidance on AI scribes

On 29 July 2026 the MHRA set out when an ambient voice technology product, or AI scribe, is a medical device. A scribe that transcribes and summarises for the clinician to review is generally not one. A scribe that suggests diagnoses or treatment options is (MHRA). For your notes, the diagnosis stays yours, whatever tool helps you write it. What the MHRA guidance means for dentists.

Recording BPE and tooth numbers

Tooth numbers. Most UK records use quadrant notation: UR, UL, LL or LR for the quadrant, then the tooth counted from the midline, 1 to 8, with deciduous teeth lettered A to E. So the upper right first molar is UR6 and the lower left second premolar is LL5. Some systems and hospital departments use FDI instead: two digits, quadrant first (1 upper right, 2 upper left, 3 lower left, 4 lower right), so UR6 is 16. Use one notation consistently, the one your practice software uses.

BPE. Record one code for each of the six sextants, written as two rows of three (upper over lower), and note when the scores call for fuller periodontal charting. Use the British Society of Periodontology’s current guidance for the codes and what each one asks you to do.

BPE 2 1 2 / 2 1 2. UR6 MO cavitated caries into dentine.

Recording consent

A consent entry should show what the patient chose, the options and risks you explained, that costs were explained, and how consent was given. If a patient chooses private over NHS treatment, record that both were offered.

If you use an AI scribe, there is a second consent: the patient’s agreement to the appointment being recorded. NHS England says patients must be told at the start of each appointment and given a clear chance to object (Mills & Reeve on NHS England’s guidance). The consent kit for AI scribes has the words to use.

Common mistakes

Note bloat

Longer is not safer. The GDC describes “note bloat” as records filled with “repetitive, formulaic, or low-value information” written defensively (GDC blog). BDA Indemnity’s Len D’Cruz put it simply: “copious notes do not necessarily mean more accurate notes” (Dentistry.co.uk).

Templates that misrepresent what happened

D’Cruz also warned that pre-populated templates cause problems when they don’t reflect what actually happened in the appointment. A template that records an oral cancer screen you didn’t do is worse than a blank line.

Gaps the defence bodies see

MDDUS warns that if care isn’t in the records, the assumption is that it wasn’t done (MDDUS), and Dental Protection says record quality is often the difference between a good and a bad outcome in a case (Dental Protection). The usual gaps:

• The medical history not recorded as checked at this visit.
• Options discussed, but not the option of no treatment.
• Risks explained, but not written down.
• Consent given, with no note of what the patient chose and why.
• Radiographs taken without a recorded justification, grade and report.
• Advice given out loud and not recorded.

Writing it up later

“Contemporaneous” means during or straight after the appointment, not at the end of the day. SDCEP describes good records as “accurate, dated, confidential, secure, contemporaneous, comprehensive, and legible” (SDCEP). Never remove an earlier entry; add a dated correction instead.

Checklist for every examination note

Print this page, or keep the list by the chair.

• Why the patient came, in their words
• Medical history checked and updated at this visit
• Smoking, alcohol and diet where they affect risk
• Extraoral and soft-tissue checks, including the oral cancer screen
• BPE for each sextant, and fuller charting where it is needed
• Findings by tooth, in one tooth notation used consistently
• Radiographs: justification, grade and report
• Your diagnosis
• Every option discussed, including no treatment
• Risks and benefits explained, including of not treating
• What the patient chose, costs explained, and how consent was given
• What you did today, with materials and anything unexpected
• Advice given
• The next step and the recall interval, set by risk
• Notes written at the time, and corrections added, never overwritten

Where an AI scribe fits

Notes take time. Dentists in a 2023 study of NHS practice in Wales estimated 7.1 minutes of note writing for each adult patient (Bannister et al., 2023). Templates save typing but invite notes that look the same for every patient. Dictation saves typing but still relies on your memory.

An AI dental scribe records the appointment, with the patient’s consent, and drafts the note in the sections above. A 2025 King’s College London study found AI transcription not yet reliable enough for notes to go unreviewed (KCL), so treat any AI draft as a draft: read it, correct it, then sign it.

Compare UK AI dental scribes →

Sources

• GDC Standards for the Dental Team, Standard 4.1 (NIMDTA training handout)
• College of General Dentistry: Clinical Examination and Record-Keeping
• NHS England: concise clinical record keeping and example SOPs (August 2026)
• GDC blog: Beyond note bloat (12 August 2026)
• Dentistry.co.uk: the GDC’s proposed Framework for Professionalism (2 June 2026)
• Dentistry.co.uk: dental experts on the record-keeping burden (16 August 2026)
• MHRA: ambient voice technology-enabled products (29 July 2026)
• MDDUS: On the record
• Dental Protection: early advice pays dividends
• SDCEP: principles of good record keeping
• Bannister et al., 2023: time spent on notes in NHS practice in Wales
• King’s College London: AI speech tools and dental record keeping (November 2025)
• NICE CG19: dental checks, intervals between oral health reviews