Dentist-Vorlage
011, comprehensive exam
Eine professionelle Dentist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Looking for a streamlined way to document dental exams? This comprehensive exam template is designed for dentists to efficiently record patient information, from medical history and presenting concerns to detailed intraoral findings and treatment plans. This template helps dentists to create thorough and accurate clinical notes. With this template, you can easily document everything from brushing habits and radiographic findings to diagnoses and treatment options. This template is ideal for any dental practice looking to improve their documentation process and save time.
Vorlagenvorschau
Medical History:
Medical history checked and updated.
Presenting:
Jane Doe arrived for comprehensive exam.
WKY:
Patient is a teacher, enjoys reading and gardening. She lives with her husband and two children.
Relevant Medical History:
Patient reports no significant medical history.
Main Concern:
Patient presents for a routine check-up and cleaning.
Dental and Social History:
Brushing:
Brushes twice daily with fluoride toothpaste, using a soft-bristled toothbrush.
Interdental Cleaning:
Flosses daily.
Diet:
Patient reports infrequent snacking, avoids sugary drinks, and consumes coffee daily.
Water:
Water consumption rated as good.
Sleep Quality:
Sleeps 7-8 hours per night, no jaw tenderness on waking.
Last Dental Visit:
Last dental visit was a check-up and cleaning on 10 October 2023.
Trauma History:
No history of dental trauma.
Smoking Status:
Non-smoker.
Extra-Oral Examination:
NAD.
Intra-Oral Examination:
Soft Tissue:
NAD.
Oral Cancer Screening:
NAD.
Dentition and Caries Charting:
18: MOD amalgam restoration. 17: MOD amalgam restoration. 16: MOD amalgam restoration. 15: MOD amalgam restoration. 14: MOD amalgam restoration. 13: Intact. 12: Intact. 11: Intact. 21: Intact. 22: Intact. 23: Intact. 24: MOD amalgam restoration. 25: MOD amalgam restoration. 26: MOD amalgam restoration. 27: MOD amalgam restoration. 28: MOD amalgam restoration. 38: Intact. 37: Intact. 36: Intact. 35: Intact. 34: Intact. 33: Intact. 32: Intact. 31: Intact. 41: Intact. 42: Intact. 43: Intact. 44: Intact. 45: Intact. 46: Intact. 47: Intact. 48: Intact.
PSR:
000, 000
Plaque:
+
Calculus:
+
NCTL:
None.
Occlusion:
Class I.
Overbite:
20%.
Overjet:
2 mm.
Crowding:
None.
Other:
None.
Imaging:
Bitewing radiographs taken.
Radiographic Findings:
Bitewing radiographs show no interproximal caries.
Problem List / Diagnoses:
1. Healthy dentition.
2. Mild gingivitis.
Discussion and Treatment Options:
1. Explained the findings of the exam and the absence of any significant dental issues. Advised on continued good oral hygiene practices.
2. Discussed the presence of mild gingivitis and recommended improved flossing technique and professional cleaning.
Patient opted to proceed with the plan below.
Treatment Plan:
1. Prophylaxis and oral hygiene instruction today.
2. 6/12 with OHT.
Post-Operative Instructions:
NV:
Recall appointment in 6 months for check-up and cleaning.
RTR:
To maintain oral health and prevent future dental problems.
Jane well on discharge.
- Sari
Additional Information:
None.
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