01/11/2024
MAIN COMPLAINT
36 : PAIN ON BITING : PATIENT REPORTS PAIN WHEN CHEWING ON THE LOWER LEFT SIDE, ESPECIALLY WITH HARD FOODS.
TREATMENT
- 36 : EXTRACTION : POIG : PWOD
- SCALING : FULL MOUTH
- 16 : FILLING : AMALGAM : VITRABOND
NOTES
PERIODONTAL DISEASE : MILD TO MODERATE POCKETING.
GROSS CALCULUS : PRESENT THROUGHOUT.
BRUXISM : PATIENT REPORTS GRINDING TEETH AT NIGHT.
REFERRAL
36 : EXTRACTION : ORAL AND MAXILLOFACIAL SURGEON : REPORT ATTACHED.
TREATMENT PLAN
- 36 : EXTRACTION : PAIN ON BITING
- 16 : FILLING : LARGE BROKEN AMALGAM
- SCALING : FULL MOUTH
PERSONAL NOTES
PATIENT IS A LONG-STANDING PATIENT OF THE PRACTICE. PATIENT IS GENERALLY PUNCTUAL FOR APPOINTMENTS.
[Date in the following format DD/MM/YYYY] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
MAIN COMPLAINT
[Main reason for visit and brief history of complaint, formatted with tooth number followed by colon, main complaint in caps, and additional information separated by colons] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
TREATMENT
[List treatments relating to each tooth or procedure in the following sequence: bullet point, tooth number/procedure, colon, details of procedure. Example:
- 25 : FILLING : ZOE : VITRABOND : FLOWABLE PACKABLE
- SCALING
- BITEPLATE : LOWER : 2.5MM DUAL LAMINATE
- 36 : EXTRACTION : POIG : PWOD] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
NOTES
[List general notes such as periodontal disease, gross calculus, subgingival calculus, poorly done root canal treatments, bruxism, anterior open bite, etc.] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
REFERRAL
[Tooth number : reason for referral and to whom referred, including any reports relating to the referral. Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Do not create or assume referrals. Examples of referral specialists include oral and maxillofacial surgeons, endodontists, periodontists, and orthodontists.]
TREATMENT PLAN
[List treatment plan, each tooth/procedure on a separate line, starting with tooth number followed by colon and reason for procedure. Example:
- 16 : CROWN : LARGE BROKEN AMALGAM AND SECONDARY DECAY
- 46 : EXTRACTION : ABSCESS UNDER POORLY DONE ROOT CANAL TREATMENT
- BITEPLATE : LOWER : 2.5MM DUAL LAMINATE] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
PERSONAL NOTES
[Any personal notes such as family details, referrer, patient preferences, punctuality, etc.] (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 or contextual notes, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)