Writing Treatment Notes Flashcards
Note
Essentials
(5)
Review of
Medical
History
Pre-
medication
Used
Anesthesia
Procedure
Performed
Post-
operative
Instructions
- Review of Medical History
(2)
ex
- Note any changes in medical history or
medications - If no changes – state that medical hx was
reviewed and no changes are noted
Example: The patient reports that she is
now taking 25 mcg of Synthroid. No other
changes to her medical history.
- Pre-medication
(1)
Examples: (2)
Make sure to include the (2)
ex
- Note any medications the patient may have
used in preparation for the appointment and
why they were used
antibiotics used for premedication,
anxiolytics, muscle relaxants, etc.
dosage and time the medications were taken
Example: The patient reports taking 2 g of
Amoxicillin 1 hour prior to the appointment
for her artificial heart valve.
- Anesthetic used
(5)
- Topical Anesthetic if used
- Amount of Anesthetic:
- Type of Anesthetic:
- Type of Injection:
- Location of Injection:
Example: After placement of topical benzocaine,
1 carp of 2% lidocaine with 1:100K epi was delivered
as a local infiltration at #7.
- Amount of Anesthetic:
state number of mgs/carps
used
- Type of Anesthetic:
2% lidocaine with 1:100K epi,
3% carbocaine plain, 4% articaine with 1:100K epi,
etc.
- Type of Injection:
ASA, long buccal, local infiltration,
inferior alveolar, PSA, etc.
- Location of Injection:
Lower right (LR), facial #4,
posterior palatal right side
- Procedure Performed
(3)
ex
- Patient presents for [procedure(s)] .
- Note any radiographs taken
Diagnosis:
Example: The patient presents for an initial diagnosis. A full
mouth series of radiographs was taken. The patient reports
some sensitivity in the UR posterior with cold. The HHX,
medication list, oral exam, perio charting and odontogram were
completed. Alginate impressions for diagnostic casts were
taken.
- Procedure Performed
* Patient presents for [procedure(s)] .
* Note any radiographs taken
Diagnosis:
(4)
Patient’s chief concern/goals for treatment
Diagnostic data that was collected during the exam
Exam started/continued from previous appointment &
completed/in progress
Diagnostic impressions taken (including material) & face bow
registration
- Procedure Performed 1
Perio:
(7)
ex
Gingival assessment and/or diagnosis
Presence of plaque/calculus
Oral hygiene instructions provided
Instrumentation used (ultrasonic, hand scaling)
Prophy paste
Fluoride application
Recommended recall interval
Example: The patient had generalized inflammation and plaque
due to inadequate home care. Calculus present around the
lingual surfaces of the mandibular anterior teeth. The patient
was disclosed and brushing and flossing techniques were
reinforced. The adult prophy was completed using ultrasonics
and hand scalers. Fine grit prophy paste used to polish followed
with fluoride varnish. Recommend a 6 month recall.
- Procedure Performed 2
Operative:
(8)
ex
Tooth # and surfaces involved
Isolation
Prep detail (surfaces, type of prep, size of prep)
Base/liner placed (if any)
Matrix type used
Etchant/bonding material
Restorative material, shade
Occlusion & interproximal contacts checked
Example: After placing a rubber dam, tooth #3 prepped
for a DO composite. All caries removed which were
extensive at the gingival and axial walls. Palodent plus
matrix used. Vitrebond placed at the axial wall and cured.
Prep was etched and rinsed, PQ1 bonding agent placed
and cured. Filtek composite in shade A2 placed
incrementally. Restoration was finished and polished and
occlusion adjusted to patient’s satisfaction. Distal contact
flossed and verified as present.
- Procedure Performed 4
Fixed:
(9)
Tooth #
Prep design
Cord size/hemostatic agent
Impression material & type of impression
Bite registration
Type of temporary crown/cement
Type of permanent cement
Occlusion & interproximal contacts checked
Porcelain shade selected
Example: Tooth #5 was prepped for a zirconia
crown. Size 0 and 1 cords soaked in hemodent
packed. Both cords were removed prior to
impressing. A quadrant impression was taken using
Affinis light and regular body materials. A temporary
crown was made using Integrity shade A2 and
cemented with Ultratemp. Occlusion was adjusted
to the patient’s satisfaction and contacts flossed.
Shade A2 selected for the crown.
- Procedure Performed 6
Removable:
(9)
ex
Impressions taken (type and materials)
Records taken
Selected shades/molds
Evaluation/adjustments made from try-in
Pt approval of esthetics
Adjustments (where)
Occlusion checked/adjusted
Patient instructions
Follow-up
Example: The maxillary custom tray was adjusted to
fit and border molding was completed with grey
stick compound. After border molding, the final
impression was taken using medium body Aquasil.
Patient’s vibrating line was marked with indelible
marker and transferred to the final impression
- Post-Operative instructions
(4)
ex
- Post operative instructions given to patient,
including any prescriptions for medications - How the patient tolerated the procedure
- Anything that was unexpected or out of the
ordinary - Date and purpose of next visit
Example: The patient tolerated SRP procedure well,
but requests to avoid use of the Cavitron in the
future. Advised a warm salt water rinse tonight and
OTC pain medications as needed for discomfort.
NV: UL and LL SRP
