Clinical note templates list

Cancelled Appt < 24-Hr Notice

The patient cancelled their appointment with less than 24-hour notice.

Patient Dismissed

The patient was dismissed from the practice because of Patient Dismissal Reason. The patient was given 30-days notice prior to dismissal from the practice, and told that the practice is still available for emergency treatment for the next 30 days while the patient is seeking another dentist.

Patient Failed Confirmed Appt

The patient's appointment was previously confirmed, and the patient did not arrive at the office for their scheduled appointment.

Return Appointment

The patient Return Appointment to finish treatment.

Anesthetic, Specific Tooth

Anesthetic, Topical was placed on the Anesthetic Area, adjacent to tooth Anesthetic for Tooth. A total of Carpules, QtyCarpules, Fraction carpules of Anesthetic, Local was injected into the Anesthetic Area using a Anesthetic, Needle Length, Anesthetic, Needle Gauge-gauge needle. A suck-back safety syringe was used to avoid inter-vesicular injection. The patient tolerated the injection and had no adverse reactions to the anesthetic.

Local Anesthetic, Brief

The patient was given Carpules, QtyCarpules, Fraction total carpules of Anesthetic, Local to achieve satisfactory local anesthesia results.

No Injection Given to Patient

No injection was given to the patient. Anesthetic, None Given for the dental treatment.

Cosmetic Aberration

The patient has Cosmetic Aberration, Cosmetic Aberration Treatable. Cosmetic Aberration Notes

Cosmetic Issue

The patient has Cosmetic LevelCosmetic Issue in the Cosmetic Area area.

Exam Type

Exam Type: Exam Type

Functional Evaluation, TMJ

A Functional Evaluation of the patient's TMJ shows the following:

Motion/Deviation: Eval TMJ, Motion/Deviation

Subluxation/Crepitus: Eval TMJ, Subluxation/Crepitus

Symptoms Reported: Eval TMJ, Symptoms Report

Diagnosis: Eval TMJ Diagnosis

Myofunctional Analysis

A Functional Evaluation, Myofunctional Analysis shows the following:

Tongue Habits: Eval MA, Tongue Habits

Lip Habits: Eval MA, Lip Habits

Speech: Eval MA, Speech

Occlusion

A Functional Evaluation of the patient's Occlusion shows the following.

Occlusion Classification: Occlusion, Classification

Left Lateral: Occlusion, Left Lateral

Right Lateral: Occlusion, Right Lateral

Space for Appliances: Occlusion, Appliance Space

Overall Spacing: Occlusion, Overall Spacing

Crowding: Occlusion, Crowding

Crossbite: Occlusion, Crossbite

Arch Length: Occlusion, Arch Length

Overbite (mm): Occlusion, Overbite (mm)

Overjet (mm): Occlusion, Overjet (mm)

Patient's perceived level of function: Occlusion, Function, Patient

Dentist's perceived level of function: Occlusion, Function, Dr.

Patient's perceived level of aesthetics: Occlusion, Aesthetic, Patient

Dentist's perceived level of aesthetics: Occlusion, Aesthetic, Dr.

Oral Hygiene

The patient's overall Oral Hygiene is Oral Hygiene, Overall. Today's exam shows the following.

Plaque: Oral Hygiene, Plaque

Calculus: Oral Hygiene, Calculus

Stain: Oral Hygiene, Stain

Food Impaction Areas: Oral Hygiene, Food Impaction

Oral Pathology

The patient has Oral Pathology Level Oral Pathology Type oral pathology. Oral Pathology Treatment is recommended. The prognosis is Oral Pathology Prognosis. Oral Pathology, Tooth Related.

Patient Habits

An evaluation of the patient's habits pertaining to their oral health shows the following.

Cigar/Cigarette Smoking: Habits, Cig Smoking

Pipe Smoking: Habits, Pipe Smoking

Nail Biting: Habits, Nail Biting

Smokeless Tobacco Use: Habits, Chewing Tobacco

Thumb/Finger Sucking: Habits, Thumb Sucking

Toothpick/Stimulator Use: Habits, Toothpick Use

Gum Chewing: Habits, Gum Chewing

Teeth Grinding/Clenching: Habits, Teeth Grind/Clench

Cheek Biting: Habits, Cheek Biting

Tongue Thrusting: Habits, Tongue Thrusting

Mouth Breathing: Habits, Mouth Breathing

Bulemia/Anorexia: Habits, Bulemia/Anorexia

Substance Abuse: Habits, Substance Abuse

Other Habits: Habits, Other

Patient Health

Patient health conditions: Health Issues

Restorative Issues

The patient exhibits Decay Level existing decay.

The patient is missing the following teeth: Tooth-Missing

The patient has the following additional restorative issues: Restorative Issues

Soft Tissue Exam

A Soft Tissue Exam shows the following:

Extraoral Head/Neck: STE Extraoral Head/Neck

Lymph Chain: STE Lymph Chain

Lips: STE Lips

Labial/Buccal Mucosa: STE Labial/Buccal Mucosa

Tongue: STE Tongue

Floor of Mouth: STE Floor of Mouth

Palate, Hard/Soft: STE Palate, Hard/Soft

Pharynx: STE Pharynx

Attempted Root Canal, Closed

Attempted root canal treatment on tooth Tooth-Receiving Treatment. Examination of the X-ray revealed that the canal has closed off. The patient has been informed that the tooth can either be extracted and crowned or have a post and core and be crowned. A treatment plan is being determined.

High Pulp Test Reading

A pulp test was administered on tooth Tooth-Select One. The pulpal reading was Pulp Test. The high test result indicates that the nerve is dead and the tooth is abscessed. The patient has agreed to Tx Plan to repair the damage.

Low Pulp Test Reading

A pulp test was administered on tooth Tooth-Select One. The pulpal reading was Pulp Test. The low result represents a normal reading for the tooth.

Crown Replaced Large Amalagam

The amalgam restoration covering the Surfaces Covered-Old surface(s) of tooth Tooth-Receiving Treatment has been replaced with a crown.

Crown to be Replaced

The Crown Type crown on tooth Tooth-Select One needs to be replaced due to Crown Replacement Reason.

Pre-Op Impression

An impression has been taken using alginate hydrocolloid in order to fabricate a temporary Tx Plan, Bridge/Crown.

Ready for Crown

Tooth Tooth-Select One is in need of a crown. The tooth has already had a Tx Plan, Ready for Crown.

Shade Guide Selected

Patient has selected Shade Guide Shade LetterShade # as the Shade Guide for use on the Tx Plan, Bridge/Crown for tooth Tooth-Receiving Treatment.

Stumpshade Selected

A stumpshade was selected to be used in conjunction with the Shade Guide for the Tx Plan, Bridge/Crown on tooth Tooth-Receiving Treatment. Shade Guide Shade LetterShade # will be used as the shade on the Surface-Select Text surface of the Tx Plan, Bridge/Crown.

Oral Hygiene Instructions

Proper technique of brushing demonstrated. Flossing with fingers and a floss holder demonstrated. Patient given a soft toothbrush and floss.

Oral Rinse

Patient rinsed with Oral Rinse after treatment.

Prophylaxis

Performed Prophy Scaling scaling with hand instruments. Flossed all contacts.

Antibiotic Pre-Med Confirmed

The patient confirmed that they pre-medicated with Rx Drug Name one hour prior to todays appointment, as instructed. The patient's dental chart indicates that they must be pre-medicated prior to any dental treatment. The patient was instructed to pre-medicate with two grams of the antibiotic (4 pills) one hour prior to todays appointment.

Antibiotic Pre-Med Negative

The patient was asked if they pre-medicated with antibiotics one hour prior to todays appointment. The patient's dental chart indicates that they must be pre-medicated prior to any dental treatment. The patient stated that they DID NOT pre-medicate prior to todays appointment. The patient was re-appointed.

Health History Updated

Before dental treatment, the patient was asked about changes to their medical history such as a recent surgery or changes in medication. Patient confirmed verbally that there have been changes in their medical history. These changes have been recorded and updated in the patients chart.

Health History, No Change

Before dental treatment, the patient was asked about changes to their medical history such as a recent surgery or changes in medication. Patient confirmed verbally that there have been NO changes in their medical history.

Health History, None

The patient has stated that they are not currently taking any medications, do not have any health issues, and have no need to be under a doctor's care at this time.

Orthodontic Extraction

The following teeth were extracted for orthodontic purposes: Tooth-Select Multiple. A letter from the orthodontist instructed that the teeth be extracted.

Orthodontic Referral

Patient has been given an orthodontic referral to discuss options with, and seek treatment from an orthodontist for correction of Ortho Issue.

Pain, Hard Tissue

The patient has pain in the following teeth: Tooth-Select Multiple

Pain, No Swelling

Patient experiences pain but has no swelling in the Quadrant-With Pain quadrant. The pain seems to be associated with tooth Tooth-With Pain.

Pain, Soft Tissue

There is evidence of Pain Manifestation on the Pain Area adjacent to tooth Tooth-Select One. From the patient's description it is determined that the pain level is Pain Level.

Pain, Swelling

Patient complains of pain and swelling in the Quadrant-With Pain quadrant. The swelling is located near the Surface-Select Text surface of tooth Tooth-Select One.

TMJ Joint Problem

Patient complained of pain in the following joint(s): TMJ Joints.

Ulcers in Mouth

The patient complained of pain in the oral cavity. An examination revealed the presence of an ulcerated, white, circular lesion of Size of Ulcer in diameter, on the mucosa in the Quadrant-With Pain quadrant, on the Surface-Select Text surface adjacent to tooth Tooth-Select One.

Severe Pulpal Exposure

Examination revealed that tooth Tooth-Select One had a severe pulpal exposure. Options were discussed, and the patient's family chose to have the tooth extracted.

Topical Anesthesia, Extraction

Topical anesthetic was used to numb the gum tissue surrounding tooth Tooth-Select One prior to the extraction of the tooth.

Deep Root Scaling, Quadrant(s)

Deep root scaling was used to remove deep calculus from the teeth in the Quadrant-Select Multiple quadrant(s) of the mouth. Patient rinsed with Oral Rinse after treatment.

Deep Root Scaling, Teeth

Deep root scaling was used to remove deep calculus from the following teeth: Tooth-Select Multiple. Patient rinsed with Oral Rinse after treatment.

Periodontal Exam Notes

A periodontal exam indicates the following for quadrant(s): Quadrant-Select Multiple.

Classification: Perio, Classification

Gingiva Color: Perio, Color

Gingival Inflammation: Perio, Inflammation

Free Gingival Margins: Perio, Margins

Interdental Papillae: Perio, Papillae

Gingiva Consistency: Perio, Consistency

Gingiva Surface Texture: Perio, Texture

Attached Gingiva: Perio, Attached Gingiva

Gingival Sulcus: Perio, Sulcus

Gingival Bleeding: Perio, Bleeding

Suppuration: Perio, Suppuration

Pattern of Bone Loss: Perio, Bone Loss Pattern

Severity of Bone Loss: Perio, Bone Loss Severity

Plaque: Perio, Plaque

Calculus: Perio, Calculus

Dentinal Hypersensitivity: Perio, Hypersensitivity

Tooth Stain: Perio, Stain

Tooth Stain Pigment: Perio, Stain Pigment

Other: Perio, Miscellaneous

Referral to Periodontist

Patient has been referred to a periodontist for further treatment.

No Medication or Antibiotic

Neither pain medication nor antibiotics were given to the patient. The patient understood that their procedure was minor and did not require the use of either pain medication or antibiotics.

Prescription

The patient has been given the following prescription:

Rx Drug Name, Rx Quantity; Rx Sig - Instructions. There are Rx Refills refills on the prescription. Prescription instructions have been given to the patient and the patient has confirmed that they understand the instructions.

Prescription to Pharmacy

The patient's prescription was Rx to Pharmacy.

Patient Referred

The patient has been referred to Patient Referred, Specialty for Patient Referred, Reason.

Patient, Consider Tx Options

The patient has been presented with several treatment options and understands that they need to schedule an appointment and return to the office for treatment when they have decided upon a treatment plan.

Treatment Importance

The importance of making and keeping treatment appointments has been discussed. A printout of costs associated with treatment has been given to the patient. The patient understands that if they do not seek immediate dental treatment the costs of restoring their dentition could increase significantly and may or may not include additional procedures such as root canals and crowns.

Add Multiple Teeth, Removable

Additional teeth have been added to the patients removable appliance: Tooth-Select Multiple.

Occlusal Bite Guard Delivered

An Occlusal Bite Guard was delivered to the patient. The patient has been instructed to wear the bite guard at night. The patient has also been encouraged to wear the guard any time they are biting or grinding their teeth.

Patient Instructions

The patient has been given their removable appliance and has been instructed to return to the office if they experience any discomfort related to the appliance or if the appliance requires any adjustments.

Chip in Tooth, Large

The Surface-Select Text surface of tooth Tooth-Select One has been chipped. The patient has been advised that since the chip is large the tooth will need Tx Plan. Patient will make an appointment for treatment.

Chip in Tooth, Small

The Surface-Select Text surface of tooth Tooth-Select One has been chipped. The patient has been advised that since the chip is relatively small the best treatment option is sanding, smoothing and polishing.

Crown Cemented

The Crown Type crown on tooth Tooth-Receiving Treatment was cemented using Cement, Permanent, phosphoric acid etchant Phosphoric Acid Etchant %, and Bonding Agent. One digital X-ray was taken to verify fit and ensure removal of excess cement. The patient received Post-Op Instructions post-op instructions.

Crown Off, Structure Sound

The crown came off tooth Tooth-Select One. Examination revealed both the tooth and the crown to be in good structural condition. Crown cleaned and re-cemented to tooth using Cement, Permanent. Patient advised that should this happen again the crown will need to be replaced.

Crown Off, Structure Unsound

The crown came off tooth Tooth-Select One. Examination revealed part of the tooth structure to have broken off with the crown. Patient has been advised that re-cementing the crown is not an option because of the broken tooth. Several treatment options were presented, including a root canal with a post and core and a new crown. Patient has agreed to Tx Plan to repair the tooth.

Fractured Crown

The Surface-Select Text surface of the crown on tooth Tooth-Select One is fractured. Patient has agreed to Tx Plan to repair the tooth.

Crown Restoration Post-Op

Patient has been given all instructions and information concerning the Crown Type crown placed today. They have been advised regarding the duration of numbness, expected sensitivity, and amount of time until they can chew. The patient has also been advised to contact the office if they experience swelling of the jaw or severe pain related to temperature changes in the mouth.

Post-Op Instructions

For today's treatment, Post-Op Instructions post-op instructions were given to the Post-Op Given.

Pat. Confirms Pregnancy, X-ray

The patient responded affirmatively when asked whether she was pregnant. X-rays will not be taken because of her condition.

Used FMX Instead of X-ray

No X-ray was taken of the patient. The most recent FMX was used instead.

X-ray, Patient NO Permission

A thorough explanation of the benefits and risks associated with the taking of digital x-rays was verbally discussed with the patient, including the necessity of taking an x-ray on tooth Tooth-Select One. Despite my recommendations to have x-rays taken, the patient refused to give permission to take x-rays and the patient understands the possible consequences of this action.