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Primary Care Physician
15-20 minutes

Brief Dental Note

This streamlined dental note template by s10.ai is crafted for general practitioners to effectively document patient visits concerning dental issues. It features sections for noting the appointment's purpose, COVID-19 screening outcomes, primary complaints, and comprehensive history of current complaints. The template also addresses dental hygiene practices, pertinent medical history, and social determinants impacting oral health. It offers a structured approach for extraoral and intraoral evaluations, oral hygiene assessments, caries risk assessment, and clinical examination findings. Furthermore, it details available treatment options, agreed-upon treatment plans, and future visit plans, making it an essential tool for precise dental documentation.

2,578 uses
4.4/5.0
E
Evelyn Carter
Template Structure

Organized sections for comprehensive clinical documentation

RFA: [Summary of Appointment Reason] (document the main reason for the patient's visit, such as routine check-up, pain, follow-up care, or specific dental concerns, as explicitly mentioned in the transcript or contextual notes. Write as a concise sentence.)
Covid questions: [COVID-19 Screening Status] (indicate whether COVID-19 screening was conducted and its result, such as positive, negative, or not performed. Only include if explicitly mentioned in the transcript or contextual notes.)
C/o: [Description of Chief Complaint] (describe the patient’s main concern, including onset, duration, severity, associated symptoms, and any aggravating or relieving factors. Write as a brief paragraph or a bullet-point list if explicitly mentioned.)
HPC: [Comprehensive History of Present Complaint] (provide a structured and chronological account of the presenting dental issue, detailing its onset, progression, exacerbating or alleviating factors, and any previous self-management attempts. Write in clear, concise sentences.)
PDH: [History of Patient's Dental Hygiene and Treatment] (summarize the patient’s dental hygiene habits, including brushing frequency, flossing, mouthwash use, and history of professional cleanings or treatments. Include details on prior dental procedures or surgeries if explicitly mentioned. Write as a brief sentence or a list.)
PMH: [Medical Conditions and Treatment History] (list medical conditions, ongoing treatments, or medications that may impact dental health, such as diabetes, hypertension, anticoagulants, or immunosuppressants. Include only if explicitly mentioned in the transcript or contextual notes.)
SH: [Lifestyle and Social Factors Impacting Oral Health] (mention social habits relevant to oral health, such as smoking, alcohol consumption, dietary patterns, and occupational risks. Write as a concise sentence and only include if explicitly mentioned.)
E/O: [Findings from Extraoral Examination] (document any extraoral observations, such as swelling, asymmetry, temporomandibular joint issues, or skin changes relevant to the dental examination. If no abnormalities are noted, default to "Nil.")
I/O ST: [Findings from Intraoral Soft Tissue Examination] (record observations of intraoral soft tissues, including inflammation, ulcers, lesions, or any abnormal changes in the mucosa. If no abnormalities are present, default to "Nil.")
OH: [Assessment of Oral Hygiene] (evaluate the patient’s oral hygiene status based on clinical examination and patient-reported habits. Select one: good, fair, or poor. Only include if explicitly mentioned.)
Caries risk: [Classification of Caries Risk] (determine the patient’s risk level for caries based on clinical findings, dietary habits, and oral hygiene. Classify as low, moderate, or high. Always include this for review and manual deletion if not applicable.)
O/E: [Observations from Clinical Examination] (document findings from the clinical examination, including dental caries, plaque accumulation, periodontal status, calculus deposits, and other notable oral conditions. Write as a concise paragraph using full sentences.)
Diagnosis: [Dental Diagnoses Confirmed] (list all identified diagnoses based on examination findings, specifying tooth numbers and conditions such as dental caries, periodontal disease, occlusal issues, or infections. Write in a structured format.)
NHS and private Options: [Treatment Options Available] (outline the treatment options available under NHS and private care, including details on the procedures, potential benefits, risks, and financial implications. Write in full sentences.)
Tx plan: [Treatment Plan Agreed Upon] (summarize the treatment plan agreed upon with the patient, specifying planned procedures, expected timelines, and necessary follow-ups. Use bullet points for clarity and include only if explicitly mentioned in the transcript or contextual notes.)
n.v.: [Plan and Purpose for Next Visit] (document the purpose and plan for the patient’s next appointment, including scheduled procedures, follow-ups, or further assessments. Write as a concise sentence or phrase.)
Sample Clinical Note

Example of completed documentation using this template

RFA: Routine examination and assessment of recent dental sensitivity.
Covid questions: Negative
C/o: 
- Sensitivity in the upper right molar area
- Onset: 2 weeks prior
- Severity: Moderate
- Aggravating factors: Cold drinks
- Relieving factors: Warm water rinses
HPC: The patient describes moderate sensitivity in the upper right molar area for the last two weeks. The sensitivity worsens with cold drinks and is somewhat alleviated by warm water rinses. No prior self-treatment has been attempted.
PDH: 
- Brushes twice daily
- Flosses occasionally
- Last dental cleaning: 6 months ago
- Previous dental work: Filling in lower left molar
PMH: 
- Hypertension, controlled with medication
- No other significant medical issues
SH: 
- Smokes 5 cigarettes daily
- Moderate alcohol intake
E/O: Nil
I/O ST: Nil
OH: Fair
Caries risk: Moderate
O/E: Clinical assessment shows plaque buildup and mild gingivitis. No visible cavities in the upper right molar area, but sensitivity tests indicate increased response in the region.
Diagnosis: 
- Sensitivity in upper right molar area
- Mild gingivitis
NHS and private Options: 
- NHS: Desensitizing toothpaste and fluoride varnish application
- Private: In-office desensitizing treatment and custom fluoride trays
Tx plan: 
- Use desensitizing toothpaste twice daily
- Schedule fluoride varnish application
- Follow-up in 4 weeks to reassess sensitivity
n.v.: Follow-up appointment in 4 weeks for sensitivity reassessment and potential further treatment.
Clinical Benefits

Key advantages of using this template in clinical practice

  • Enhance your dental practice's efficiency and accuracy with our comprehensive clinical template, designed to streamline patient documentation and improve care delivery. This template incorporates high-search healthcare and clinical keywords, ensuring your practice stays at the forefront of digital health trends. It covers all essential aspects of patient visits, from the Reason for Appointment Summary to detailed History of Present Complaint, and includes sections for Covid Screening, Chief Complaint, and both Extraoral and Intraoral Examination Findings. With structured fields for Patient's Dental Hygiene and Treatment History, Relevant Medical Conditions, and Social and Lifestyle Factors, this template supports thorough patient assessments. Additionally, it offers a clear framework for documenting Clinical Examination Observations, Confirmed Dental Diagnoses, and Available Treatment Options under NHS and private care. By adopting this template, clinicians can enhance patient communication, ensure comprehensive care planning, and facilitate seamless follow-ups, ultimately leading to improved patient outcomes and satisfaction. Explore and implement this template to elevate your practice's clinical documentation standards today.
Frequently Asked Questions

Common questions about this template and its usage

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Brief Dental Note