AOX Consult Casey Dental

**Smile Consult** **Provider: [Provider Name]** (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) **Assistant: [Assistant Name]** (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) **Batch: [Batch Info]** (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) --- **1. History of Presenting Complaint** [Document symptoms, reasons for visit, progression, and patient motivations in full sentences] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) --- **2. Past Medical History (MHx)** - [Chronic illnesses] (Only include if explicitly mentioned…) - [Medications] (Only include if explicitly mentioned…) - [Allergies] (Only include if explicitly mentioned…) - [Relevant surgeries] (Only include if explicitly mentioned…) - [ASA classification] (Only include if explicitly mentioned…) --- **3. Dental History (DHx)** - [Previous dental treatments (implants, dentures, root canals, etc.)] (Only include if explicitly mentioned…) - [History of extractions or infections] (Only include if explicitly mentioned…) - [Periodontal status] (Only include if explicitly mentioned…) - [Previous prosthesis failures] (Only include if explicitly mentioned…) --- **4. Social History (SHx)** - [Smoking, vaping, alcohol] (Only include if explicitly mentioned…) - [Occupation] (Only include if explicitly mentioned…) - [Financial/social support] (Only include if explicitly mentioned…) - [Anxiety or relevant social factors] (Only include if explicitly mentioned…) --- **5. Clinical Examination** - Extraoral: [TMJ, symmetry, lymph nodes] (Only include if explicitly mentioned…) - Intraoral: [Mobility, caries, retained roots, gingival inflammation, mucosa] (Only include if explicitly mentioned…) - Prosthetic space: [Interarch clearance, occlusion, ridge form] (Only include if explicitly mentioned…) --- **6. Radiographic and Diagnostic Investigations** - [OPG/CBCT findings: bone volume, sinus proximity, nerve pathway] (Only include if explicitly mentioned…) - [Extraoral/intraoral photographs taken] (Only include if explicitly mentioned…) - [Study models or TRIOS scans, noting leaf gauge or increased OVD if relevant] (Only include if explicitly mentioned…) --- **7. Diagnosis** - [Terminal dentition if relevant] (Only include if explicitly mentioned…) - [Generalised bone loss] (Only include if explicitly mentioned…) - [Other clinical/radiographic diagnoses stated] (Only include if explicitly mentioned…) --- **8. Treatment Options Discussed** [Summarise options explicitly discussed, under Pros, Cons, Costs, and Patient Reactions.] (Only include if explicitly mentioned…) - Option A: [Save Teeth] (Only include if explicitly mentioned…) - Option B: [Remove Teeth] (Only include if explicitly mentioned…) - [No Treatment option] (Only include if explicitly mentioned…) - [Conventional Dentures] (Only include if explicitly mentioned…) - [Implant-Retained Overdentures] (Only include if explicitly mentioned…) - [All-on-X Fixed Prosthesis] (Only include if explicitly mentioned…) - [Combination Approaches] (Only include if explicitly mentioned…) --- **9. Risks and Complications Discussed** [List risks only if explicitly mentioned, e.g., post-op pain, swelling, sinus issues, paraesthesia, fractures, implant failure, bruxism management, smoking-related complications.] (Only include if explicitly mentioned…) --- **10. Maintenance Plan** [List follow-up hygiene, reviews, imaging, prosthesis maintenance if discussed.] (Only include if explicitly mentioned…) --- **11. Treatment Sequence** [List treatment sequence steps only if discussed: GA, extractions, implant placement, temporary prosthesis, reviews, dietary advice.] (Only include if explicitly mentioned…) --- **12. Payment Options** [List payment methods only if explicitly mentioned: superannuation withdrawal, plans, rebates, deposits.] (Only include if explicitly mentioned…) --- **13. Patient Autonomy and Decision** - [Patient encouraged to take time] (Only include if explicitly mentioned…) - [No pressure to proceed] (Only include if explicitly mentioned…) - [Options outlined clearly] (Only include if explicitly mentioned…) - [Clinician recommendation noted] (Only include if explicitly mentioned…) - [Final patient decision documented] (Only include if explicitly mentioned…) --- **14. Wrap-Up and Next Steps** - [Asked if patient had further questions] (Only include if explicitly mentioned…) - [Referred to Treatment Coordinator] (Only include if explicitly mentioned…) - [Plan to be formulated in Smile Connect] (Only include if explicitly mentioned…) - [Advised to contact if further clarification needed] (Only include if explicitly mentioned…) --- **15. Additional Notes or Comments** [Document emotional state, additional clinical details, dialogue, and direct quotes from patient or clinician] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.) --- (For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Never come up with your own patient details, exam findings, investigations, treatment options, risks, complications, maintenance, payment details, decisions, or next steps—use only the transcript, contextual notes or clinical note as reference. If any information has not been explicitly mentioned, do not state that it was not mentioned; simply omit it. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)