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Clinical Note Templates

Clinical Note Templates

  • 29700

No clinical note, not a bad or incomplete note, is the most common issue resulting in headaches for dentists, billing staff and other stakeholders.

 

Adequate documentation to explain who, what, why, and how is essential.

 

Document like you wrote in dental school, but in a fraction of the time.

 

Our collection of templates will save you time, $ and headaches when your records are scrutinized by 3rd parties (a certainty in today’s insurance and regulatory environments).

 

The templates are easy to upload to Open Dental, Eaglesoft and other software. Dentrix users will need to build these templates into their systems, which is not hard – it’s just not as simple as Open Dental or Eaglesoft.

 

The templates are delivered as a series of Word(R) documents, so users can download and modify them to suit their needs prior to installing in their dental software.

 

Templates cover:

  • Exams
  • Restorative
  • Oral Surgery
  • Pediatrics
  • Endodontics
  • Implants
  • Sedation


  

Sample Template - Extraction 

Pt presents for extraction of tooth _____ due to; diagnosis:____

RMHX: No changes from medical history recorded on (enter date of previous medical history update):   

BP:

Pulse: 

Time Out Procedure Performed Prior to Extraction. Verified informed consent was signed by patient/ caregiver.

Medical Necessity

___ Tooth is non-restorable due to caries 
___ Tooth is non-restorable due to the extent of fractured off tooth structure 
___ Pulpal and/or periapical pathology that cannot be treated 
___ Pathological cyst formation 
___ Second or subsequent episodes of pericoronitis (unless the first episode is particularly severe), that cannot be resolved through the use of antibiotics, irrigations, or other topical treatment 
___ Osteomyelitis 
___ Cellulitis 
___ Tumor removal that also requires removal of tooth for access 
___ Tooth is positioned ectopically and prevents the eruption of an adjacent tooth 
___ Internal/external resorption of a tooth or adjacent tooth 
___ Tooth in aberrant position that is causing bone loss on adjacent tooth/teeth 
___ Tooth/teeth impeding orthognathic surgery, reconstructive surgery, trauma surgery, or other jaw surgery

___ exfoliation not imminent

___ have x-ray showing clearly the adjacent and opposing teeth

___ bicuspid extraction(s) for orthodontic care

 

Anes: ___ carp 4% citanest plain; ___ carp infiltrate of 4% sept with 1/100k epi and ___ carp 2 lido with 1/100k epi

Elevated flap, sectioned tooth # ___ and/or removed bond.

OR

Elevated and extracted tooth #___ without complication; placed digital pressure, irrigated with sterile saline; hemostasis achieved

Oral and written post-op instructions given written

Extraction: Complete / Incomplete

Pt tolerated the procedure well, instructed to call or return to the office if any concerns or complications

NEXT VISIT --

Assisted by/ Notes completed by: (insert full name and title here)

Reviewed and approved by Dr. (Insert Name of Dentist)



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