01/11/2024
Dear Doctor,
Thank you very much for your kind referral of Emily Carter. I saw Emily today for an orthodontic assessment. Emily's main concern is the alignment of her upper front teeth, which she feels impacts her smile and confidence. She also reports difficulty in thoroughly cleaning the crowded areas, leading to concerns about potential dental health issues.
A clinical extra-oral examination showed a symmetrical facial profile with a slightly convex profile. Lip posture was competent at rest. No significant soft tissue findings were noted. Intra-orally Emily presented with moderate crowding in the upper anterior region, a 3mm overjet, and a mild Class II molar relationship bilaterally. There was also some mild lower incisor crowding.
The panoramic radiograph showed the presence of all permanent teeth, with no significant abnormalities. Root development appeared complete.
I have suggested the following treatment options:
Comprehensive orthodontic treatment with fixed appliances.
Invisalign treatment.
I have recommended comprehensive orthodontic treatment with fixed appliances to address the crowding and improve the overall alignment and occlusion.
Thank you for your continued support.
Warm regards,
Dr. Sarah Jones
South Coast Orthodontics
[Date in DD/MM/YYYY format]
Dear Doctor,
Thank you very much for your kind referral of [Patient's full name]. I saw [Patient's first name] today for an orthodontic assessment. [Patient's first name]'s main concern is [describe the patient’s chief complaint in paragraph form, including any functional or aesthetic concerns raised during the consultation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences and in paragraph format.)
A clinical extra-oral examination showed [describe extra-oral features such as facial profile, symmetry, lip posture, and any soft tissue findings]. (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences and paragraph format.) Intra-orally [Patient's first name] presented with [describe intra-oral findings including molar relationships, crowding, overjet/overbite, spacing, crossbites, or other relevant occlusal or dental findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentence and in paragraph format.)
The panoramic radiograph showed [describe radiographic findings including developing dentition, presence or absence of teeth, root development, or other relevant abnormalities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentence format.)
I have suggested the following treatment options:
[treatment options discussed with patient and/or guardian] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Do not include pricing or detailed procedural notes. Write each treatment option on a new line, without bullet points or dashes. End each line with a full stop.)
I have recommended [treatment sequence recommended based on clinical findings and discussion with patient/guardian] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentence format.)
Thank you for your continued support.
Warm regards,
[Clinician full name]
South Coast Orthodontics
(Never come up with your own patient details, complaints, findings, treatment options or plan – 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, do not state that it has not been mentioned, simply omit the placeholder or section.)