Periodontist-Vorlage
New Patient Note
Eine professionelle Periodontist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
This New Patient Note template is designed for periodontists to document comprehensive initial assessments of new patients. It includes sections for chief complaints, detailed dental and medical histories, and thorough intra and extra oral examinations. The template also covers radiographic findings, diagnoses, prognoses, and treatment plans. Periodontists can use this template to ensure all relevant information is captured during the first visit, facilitating effective treatment planning and patient communication. This template is ideal for creating structured and detailed periodontal documentation, enhancing patient care and clinical efficiency.
Vorlagenvorschau
Referring Doctor: Dr. Emily Johnson
Treatment coordinator: Sarah Lee
Chief Complaint:
- Swollen and bleeding gums for the past 3 weeks
History of Presenting Complaints:
- The patient reports swollen and bleeding gums that started 3 weeks ago. The symptoms have progressively worsened, especially after brushing. The patient experiences mild pain and discomfort, which is alleviated by using a soft-bristled toothbrush. No cosmetic concerns were mentioned.
Past Dental History:
- The patient had a root canal treatment on the upper right molar in 2019, which was successful. No significant dental diseases or injuries reported.
Past Medical History:
- The patient has a history of hypertension, managed with medication. No known allergies. Currently taking Lisinopril.
Personal History:
- The patient brushes twice daily but does not floss regularly. No habits of clenching, grinding, or tobacco use. Occasional alcohol intake reported.
Family History:
- The patient's mother had a history of periodontal disease.
Extra Oral Examination:
- No lymph node enlargement. Facial symmetry is normal. TMJ examination shows normal range of motion.
Intra Oral Examination:
- Soft tissue examination reveals inflamed and swollen gingiva, particularly in the anterior region. Gingival examination shows redness, bleeding on probing, and moderate plaque accumulation. Hard tissue examination indicates no caries or missing teeth. Oral hygiene status is fair based on the OHI index. Occlusion analysis shows normal occlusion with no significant findings.
Radiographic Findings:
- Panoramic radiograph shows mild bone loss around the molars. No caries or cysts detected.
Laboratory Investigations:
- Blood sugar levels are within normal range. No other investigations conducted.
Diagnoses:
- Generalized gingivitis with localized periodontitis.
Prognosis:
- Good overall prognosis with appropriate treatment. Teeth at risk include the lower molars due to localized periodontitis.
Treatment:
- Scaling and root planing recommended. Oral hygiene instructions provided, including the use of interdental brushes. Follow-up appointment scheduled in 4 weeks.
Financial Notes: Discussed treatment costs and insurance coverage with the patient.
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