History and examination
Needs to be comprehensive under the following headings: PCO, HPC, PDH, MH, SH, FH, EOE, IOE, PERIO, TSL, Reported OH habits
Also consider: Language barriers, Anxiety ?
Include a copy of then odontogram if beneficial
Appropriate special investigation(s)
Radiographs need to be properly reported on including: Type of radiograph. Justification, Quality, Teeth visible, Cavities, Restorations, Bone levels, Pathology ...etc
Any other appropriate investigations: Mobility, Tooth Slooth, Percussion (axial and lateral), Sensibility Testing (cold spray on CWP), Sensitivity Testing (air from 3-in-1), Palpation over root apices, Transillumination, Fremitus... etc
Interpretation of clinical findings
Diagnosis - provisional and differential as appropriate
Information given to patient - improving OH, Sugar, Fluoride, Smoking, TSL advice... etc
Justification of actions
Treatment options - including discussion of the pros and cons of each
Patient feedback - what option did they go for and why. Did they compromise on your advised plan?
Consent - verbal/written
Quality of clinical work
Accurate write up of treatment carried out. Most of this should be in your clinical notes
Include any post op radiographs here (with appropriate reporting)
Ability to reflect on own work
Candid reflection on what went well and what can be improved
Evidence base and referencing
Reference appropriate national guidelines and select journal articles
Accuracy of the write up
as long as you have included all the above it should be fine