Dental Care Documentation (for Insurance or Legal Use) Template

Dear Mr. John Smith,
I am writing to deliver a detailed Dental Treatment Report for Ms. Emily Johnson, who visited our clinic for evaluation and care on 1 November 2024. This report is intended for insurance claim purposes and encompasses details of diagnosis, treatment administered, costs incurred, and supporting clinical findings as requested.
Patient Information
- Full Name: Emily Johnson
- Date of Birth: 15 March 1985
- Patient ID/Reference Number: 123456
- Insurance/Claim Number: INS789012
Incident & Clinical Background
- Date of Incident: 20 October 2024
- Nature of Incident: Motor vehicle accident
- Initial Presentation: Severe pain in the lower jaw, swelling on the right side of the face, and difficulty in chewing.
- Relevant Medical History: History of hypertension and previous dental caries.
Clinical Examination & Findings
Extraoral Examination (E/O):
- Facial swelling: Present, right mandibular region, moderate severity
- TMJ assessment: Restricted movement, pain on palpation
- Lymph node evaluation: Enlarged, tender, submandibular
Intraoral Examination (I/O):
- Soft tissue condition: Inflammation and ulceration on the right buccal mucosa
- Periodontal health: Gingival inflammation, pocket depths of 4-5mm, moderate mobility
- Hard tissue assessment: Fracture of the right lower molar, caries on the left upper premolar
- Occlusion & function: Changes in bite, pain on occlusion
Radiographic & Diagnostic Findings:
- Radiographs taken: Periapical and OPG
- Findings: Fracture of the right lower molar, caries on the left upper premolar, no periapical pathology
Diagnosis & Justification for Treatment
- Primary Diagnosis: Fractured right lower molar due to trauma from the accident
- Secondary Diagnosis: Caries on the left upper premolar requiring restoration
Treatment Provided
During the course of treatment, the following procedures were performed:
- Restorative Treatment: Composite filling on the left upper premolar
- Surgical Treatment: Extraction of the fractured right lower molar
- Emergency Procedures: Pain relief management with analgesics
Cost Breakdown & Justification
- Total cost of treatment: $1,200
- Insurance coverage (if known): $800
- Out-of-pocket cost for patient: $400
Prognosis & Future Treatment Recommendations
- Prognosis: Good, with expected full recovery following extraction and restoration
- Follow-up required: Regular monitoring and maintenance therapy every six months
- Further treatment considerations: Possible implant placement for the extracted molar in the future
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Declaration & Clinician’s Signature
I, Dr. Thomas Kelly, confirm that the information provided in this report is accurate and based on clinical findings, diagnostic evidence, and professional assessment.
Clinician’s Name & Qualifications: Dr. Thomas Kelly, BDS  
Provider Number (if applicable): 987654  
Clinic Name & Address: s10.ai, 123 Dental Street, London  
Signature: ________________________  
Date: 1 November 2024