Record Keeping

When writing up your notes, they need to be comprehensive but also concise.

Formulating your own notes templates is a great way to save time but also ensure you don't miss out important information.

Some suggested headings you may wish to use in your templates can be found below:

NEW PATIENT ASSESSMENT

Dentist: 

Nurse:      

Chaperone: 

Language barrier: 

Introduced self & nurse. Examination explained.

PCO:      

HPC: 

PDH:      

Attendance: 

Anxiety: 

MH:

- Medical conditions: 

- Medication: 

- Allergies: 

SH:

- Occupation: 

- Tobacco: 

- Alcohol: 

- Habits: 

- Contact Sports: 

EOE:

- Symmetry: 

- Lymph: 

- TMJ: 

- MoM: 

- Opening: Range of movement? Deviation?

- Lips: 

- Other: 

IOE:

- Soft Tissues – lips, fauces, cheeks, hard palate, soft palate, tongue, FoM: 

- Occlusion: 

- Hard Tissues: 

- 3rd Molars: 

- Prosthesis: 

- Access/Visibility: 

TSL:

- Type: 

- Severity: 

- Location: 

- Pt awareness: 

- Currency: 

PERIO:

- BPE: 

- OH: 

- Recession: 

REPORTED HABITS:

- Cleaning Regime: 

- Sugar Intake: 

TESTS:

- Mobility: 

- Tooth Slooth: 

- Percussion (axial and lateral): 

- Sensibility Testing (cold spray on CWP): 

- Sensitivity Testing (air from 3-in-1): 

- Palpation over root apices: 

- Transillumination: 

RADIOGRAPHS:

RADIOGRAPH REPORT – BW

Justification:

Quality: 

Cavities: 

Restorations:

Bone levels: 

Bone density and quality: 

Calculus: 

Other findings: 

DIAGNOSIS:

- High Caries Risk Pathway: Yes / No

- Caries: 

- Pulpal/ Periapical Issues:

- TSL:

- Other: 

PERIO DIAGNOSIS:

Periodontitis 

- EXTENT: Generalised  /  Localised  /  Molar-Incisor Pattern

- STAGING: Stage 1 - Early/Mild (<15%)  /  Stage 2 - Moderate (coronal third)  /  Stage 3 - Severe (Mid third)  /  Stage 4 - Very Severe (apical third)

- GRADING: A - Slow Progress (<0.5)  /  B - Moderate Progress (0.5-1.0)  /  C - Rapid Progress (>1.0)

- STABILITY: Stable - BoP <10%; PPD <4mm; No BoP at pockets  /   Remission - BoP >10%; PPD <4mm; No BoP at pockets  /  Unstable - PPD >5mm OR PPD >4mm with BoP

- RISK FACTORS: Poor OH  /  Smoker  /  Family History  /  Diabetes

Grading = %bone loss ÷ patient age

TREATMENT OPTIONS:

Discussed findings

Showed pt radiographs - explained caries / interproximal calculus / bone loss / pathology as appropriate

- Discussed Tx options and explained risk/benefits: 

- Potential changes to proposed plan:

- Possible Complications:

- Restoration Longevity:

- Maintenance Required:

TREATMENT PLAN:

- Direct Restorations:

- Indirect Restorations:

- Prosthesis:

- Perio Tx:

- Referral(s):

COMPLIANCE, TIMELINES & PATIENT AVAILABILITY:

Discussed importance of phasing treatment.

Discussed timelines involved with Tx

- Discussed patient compliance needed:

- Estimated number of appointments: 

- Patient availability:

FURTHER ASSESSMENT(S) REQUIRED:

???

PATIENT FEEDBACK:

???

INFO GIVEN TO PATIENT:

- Plaque Control:

- Sugar Intake:

- Fluoride:

- TSL:

- Smoking: 

RISK ASSESSMENT:

- Caries: 

- Perio: 

- CA:

- TSL:

TREATMENT TODAY:

???

VISIT PLAN:

1. 

2. 

3. 

4. 

HYGIENIST PRESCRIPTION:

???

DIRECT RESTORATION

Dentist: 

Nurse:      

Chaperone: 

Language barrier: 

MH: checked and updated ???

PLAN:

- Discussed today's planned treatment: 

- Warnings given:

- Patient Questions:

- Consent:

- Hand signals:

LOCAL ANAESTHETIC:

- Topical Anaesthetic:

- Type:

- Route of Administration:

- Volume administered:

- Batch No.:

- Expiry Date:

DIRECT RESTORATION 

- Material selection:

- Occlusion checked:

- Isolation: 

- Access: 

- Preparation: 

- Caries: 

- Cavity opening: 

- Cavity depth: 

- Cavity checked: 

- Air abrasion: 

- Matrix: 

- Wedge: 

- Pulp cap: 

- Etch

- Prime & Bond: 

- Base layer: 

- Restorative Material: 

- Shade: 

- Light cure: 

- Shaped/Polished: 

- Margins checked: 

- Occlusion checked: 

- Sharps:

- POIG: