Dentrix Ascend includes a collection of default clinical note templates. Unless you have customized your clinical note templates, your database should include these default templates.
Each table below corresponds to a category of the clinical note templates. For each template, the name, note text, and quick-picks are provided.
Tip: You can click (or tap) any quick-pick link below to view the options that will be presented when a clinical note is entered from the template that contains that quick-pick.
Cancelled Appt < 24-Hr Notice
The patient cancelled their appointment with less than 24-hour notice.
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.
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.
The patient has Cosmetic Aberration, Cosmetic Aberration Treatable. Cosmetic Aberration Notes
The patient has Cosmetic LevelCosmetic Issue in the Cosmetic Area area.
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
A Functional Evaluation, Myofunctional Analysis shows the following:
Tongue Habits: Eval MA, Tongue Habits
Lip Habits: Eval MA, Lip Habits
Speech: Eval MA, Speech
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.
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
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.
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 conditions: Health 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.
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.
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.
Patient rinsed with Oral Rinse after treatment.
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.
The following teeth were extracted for orthodontic purposes: Tooth-Select Multiple. A letter from the orthodontist instructed that the teeth be extracted.
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.
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.
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.
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.
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.
Removable Prosth etics
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.
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.
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.
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.
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.
Why isn't there a category for "Oral Surgery"?
Does seem like an oversight. Others have requested this and other categories. Be sure to go to the Feature Requests forum, search for those requests by keywords, and "like" the desired requests. This will add more weight to them. Requests with the most votes tend to be made a higher priority.
Please sign in to leave a comment.