Comprehensive Dental Exam

Practitioner Details: [Enter full name including prefix and role of clinician] Type of Examination Conducted: [Describe the type of examination conducted and specify if consent was obtained] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.) Presenting Complaint: [Describe presenting complaint in the patient’s own words] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.) Dental History: [Describe relevant dental history, including previous treatments, last dental review and dental habits] (Only include if explicitly mentioned. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.) Medical History: [Describe relevant medical and surgical history] (Only include if explicitly mentioned. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.) Social History: [Describe relevant social history including smoking status, drug and alcohol use, work or study details] (Only include if explicitly mentioned. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.) Medications: [List any medications patient is taking, including over-the-counter and herbal supplements] (Only include if explicitly mentioned. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.) Allergies: [List any allergies to medications, latex, food or other] (Only include if explicitly mentioned. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.) Clinical Findings and Observations: E/O Examination: [Extra-oral examination including TMJ, lymph nodes, lips, and facial symmetry] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) I/O Examination: Soft-tissue examination: [Intra-oral findings on soft tissues – buccal mucosa, tongue, palate, FoM, vestibule] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Oral cancer screen (FoM, palate, pharynx, soft tissues): [Findings suggestive of pathology or “NAD”] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Gingiva: [Describe colour, contour, bleeding, inflammation, exudation or other findings] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Hard tissue examination: [Findings including caries, missing/restored teeth, mobility, impactions, wasting disease, anomalies] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Oral Hygiene Status: [Record hygiene status using clinical indicators or scales (e.g., good, fair, poor)] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Occlusion analysis: [Describe occlusion type, overbite/overjet, open contacts, crowding, etc.] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Other I/O findings: [Record any intra-oral findings not captured above] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Radiographic Findings: [Record findings from current or past radiographs, including pathology and bone levels] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Other Investigations: [Mention any blood tests, lab tests, and relevant results with dates] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Biopsy Findings: [Summarise results of any histological investigations] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Diagnosis: [Primary diagnosis and any differential diagnoses] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Treatment Options Discussion: [Document risks, benefits, costs, and alternatives discussed with the patient] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) [Include patient questions, concerns, and decisions] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Proposed Treatment Plan: [Record the proposed plan including procedures, sequencing, and patient preferences] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Consent: [Document whether consent was obtained for treatment/procedures] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Procedures Conducted: [Detail procedures carried out including anaesthesia, instruments, steps] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Instrument Tracking: [Record instrument batch/sterilisation tracking numbers] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Coding of Dental Service/s Provided: [Document any coding, ICD or CPT references used for billing or reporting] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Medications/Therapeutics: [List prescribed, administered, or dispensed meds with name, quantity, dosage, and instructions] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Advice Provided: [Summarise home care, oral hygiene education, dietary advice, post-treatment care] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Follow-Up and Referrals: [Note planned reviews, referrals, and cost quotes if applicable] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Unusual Events: [Document complications, adverse events, or unusual responses] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Additional Digital and Laboratory Information: [Include CAD/CAM records, lab instructions or comms with technician] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Final Notes: [Clinician summary, further recommendations, and session outcomes] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) Other Details: [Details of substitute decision-maker, special consent arrangements, or FTAs] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) [Document patient failure to attend and follow-up actions taken] (Only include if explicitly mentioned. If NAD, write NAD. If not mentioned write N/A.) (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 section blank if not explicitly mentioned. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)