Oral Maxillofacial Surgeon Template

BL - Consult Notes

A professional Oral Maxillofacial Surgeon template for healthcare professionals.

About this template

Need a clear and concise way to document patient consultations? This **clinical notes template** is perfect for Oral Maxillofacial Surgeons. It provides a structured format to record subjective information, past medical history, objective findings, assessment, and a detailed plan. This template ensures all critical aspects of a consultation are captured, aiding in accurate record-keeping and effective patient care. Easily adaptable for use with Heidi, this template streamlines your documentation process, saving you time and improving the quality of your notes.

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**Consult Notes** DATE: 1 November 2024 --- **John Smith** **Subjective:** Patient presents today for consultation regarding a painful, non-healing extraction site on the lower left mandible. The patient reports the pain has been constant for the past three weeks, described as a throbbing ache, and is exacerbated by chewing. The patient reports the pain is constant, rated as a 7/10 on the pain scale, and is not relieved by over-the-counter pain medication. The patient reports that the pain is worse when eating and drinking. The patient has tried rinsing with warm salt water, which provides minimal relief. There has been no improvement in the pain over the past three weeks. This is the first time the patient has experienced this issue. The pain is significantly impacting the patient's ability to eat and sleep. Associated symptoms include swelling and redness around the extraction site. **Past Medical History:** * Hypertension * Type 2 Diabetes * Previous extraction of tooth #18 Patient is a non-smoker, drinks alcohol socially, and works as a software engineer. No known drug allergies. Father had a history of heart disease. No known exposure history. * Up to date on all vaccinations. Patient reports they are concerned about the possibility of infection and the impact on their ability to eat. **Objective:** * Temperature: 37.2°C * Pulse: 88 bpm * Blood Pressure: 130/80 mmHg * Oxygen Saturation: 98% on room air * **Oral Examination:** Swelling and erythema noted at the extraction site of tooth #18. Exposed bone is visible. Tenderness to palpation. No purulent discharge. * **Radiographic Findings:** Panoramic radiograph reveals a non-healing extraction site with possible osteomyelitis. **Assessment:** * Non-healing extraction site with possible osteomyelitis. * Rule out: Chronic osteomyelitis, sequestrum, or other bony pathology. **Plan:** * Prescribe antibiotics (Amoxicillin 500mg PO TID x 7 days). * Recommend a course of chlorhexidine mouthwash twice daily. * Schedule a follow-up appointment in one week to assess healing. * Discussed the need for possible surgical intervention, including bone debridement and grafting, if the condition does not improve. * Patient education on oral hygiene and signs of worsening infection. **Note to Admin:** * Patient was informed of the risks and benefits of the proposed treatment plan. * Patient was provided with written instructions and a prescription for antibiotics. * Schedule follow-up appointment for 7 days.

**Consult Notes** DATE: [today's date] --- **[patient full name]** **Subjective:** [reason for visit or chief complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as short paragraph.) [symptom characteristics including duration, timing, location, quality, severity, and context] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as paragraph.) [symptom modifiers and self-management strategies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as paragraph.) [symptom progression over time] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as paragraph.) [details of any previous episodes and outcomes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as paragraph.) [impact on daily activities] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as paragraph.) [associated symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as list.) **Past Medical History:** [relevant medical and surgical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as list.) [relevant social history including lifestyle, occupation, substance use, or social determinants] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as paragraph.) [relevant family history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as list.) [exposure history including travel or occupational exposures] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as paragraph.) [immunisation history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as list.) [other relevant subjective information] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write in paragraph.) **Objective:** [vital signs including temperature, pulse, blood pressure, oxygen saturation, etc.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as list.) [physical or mental state examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points grouped by system.) [completed investigations and their results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as list.) **Assessment:** [diagnosis or clinical impression] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points.) [differential diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points.) **Plan:** [summary of recommendations, counselling, planned investigations, treatments, follow-up actions, and referrals] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points.) **Note to Admin:** [specific quotes and item numbers for administrative staff] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as bullet points or short paragraphs.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, plan for continuing care, or activity log information – 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 the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)

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