Routine Examination & Prophylaxis
Clinician: [Clinician’s Name] (only include [Clinician’s Name] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Date: [Date of Examination] (only include [Date of Examination] if it has been explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.)
Reason for Visit:
[Describe the patient’s reason for attending: Mention whether the visit is a routine check-up, recall visit, or any specific concerns reported by the patient, such as sensitivity, pain, or aesthetic issues.](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Medical History Update:
[List any relevant medical updates, medications, or allergies. Include any changes in the patient’s medical history, medications, or allergies since their last visit.](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Dental History Update:
[Describe any dental treatments since the last visit. Include any dental treatments the patient has undergone since their last visit, including fillings, crowns, extractions, root canals, orthodontics, or gum treatments.](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Oral Hygiene Habits:
[Summarise the patient’s oral hygiene routine. Include brushing frequency, flossing habits, mouthwash use, and any concerns related to oral hygiene. Document any advice given regarding oral hygiene improvement.](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Extraoral Examination (E/O):
[Describe findings from the extraoral examination. Assess facial symmetry, TMJ function, lymph nodes, and soft tissue conditions.](Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Intraoral Examination (I/O):
[Describe intraoral findings. Document soft tissue condition, periodontal health, caries status, restorations, occlusion, and any other significant findings.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
- Soft Tissues: [Describe findings related to the buccal mucosa, tongue, palate, floor of the mouth, and vestibule] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
- Gingiva: [Assess gingival condition, including inflammation, recession, bleeding, and attachment loss] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
- Hard Tissue: [Evaluate condition of teeth, restorations, caries, fractures, attrition, erosion, abfractions, and other findings] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
- Occlusion: [Assess occlusal findings, including class of occlusion, overbite, overjet, crossbite, crowding, spacing, and bruxism] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Periodontal Assessment:
- Plaque and Calculus Levels: [Describe plaque and calculus deposits] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
- Bleeding on Probing (BOP): [Document bleeding sites and severity] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
- Pocket Depths: [Mention probing depths if periodontal charting was conducted] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
- Gingival Recession: [Document any recession present] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
- Periodontal Status: [State overall periodontal health] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Radiographic Examination:
[Describe radiographs taken and key findings. Mention if radiographs were taken during this visit and specify type: bitewings, periapical, OPG, CBCT. Include findings such as caries, periapical pathology, bone levels, impacted teeth, or any other abnormalities.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Scaling and Cleaning:
- Plaque and Calculus Removal: [Describe scaling procedure performed. Include whether ultrasonic or hand scalers were used and areas treated.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
- Stain Removal/Polishing: [Document if polishing was performed. Mention type of polishing paste and method used.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
- Fluoride Treatment: [Describe fluoride application if done. Mention fluoride type, concentration, and application method.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
- Oral Hygiene Instructions Given: [Summarise any patient education on home care. Mention brushing and flossing techniques demonstrated, recommended products, and dietary advice given.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Findings & Diagnoses:
[List any new findings or diagnoses. Include conditions such as caries, periodontal disease, occlusal issues, or soft tissue.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Treatment Recommendations & Plan:
[Outline any treatment recommendations based on findings: Include recommended procedures such as fillings, periodontal treatment, occlusal adjustments, or further investigations required.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Referral:
[Indicate if referral to a specialist is necessary] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Patient Education & Preventative Advice:
[Summarize preventative advice provided to the patient] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
Next Recall Appointment:
[Specify recommended follow-up interval] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note.)
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(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care—use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been explicitly mentioned in your output—just leave the relevant placeholder or omit the placeholder completely.)
(Use as many lines, paragraphs, or bullet points as needed to capture all the relevant information from the transcript.)