Dental Extraction Note

**Subjective** [chief complaint] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Include the presenting complaint such as pain, swelling, discomfort, or mobility, the affected tooth number, and duration if mentioned.) [relevant dental and medical history] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Include any significant past dental treatments or medical alerts relevant to the extraction.) **Assessment** [extra-oral findings] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely.) [intra-oral findings] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Include caries, periodontal condition, and vitality testing if relevant.) [radiographic findings] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Include periapical radiolucency, bone support, and root morphology.) [diagnosis] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Include the diagnosis of the affected tooth.) **Consent** "Risks of extraction discussed including pain, bleeding, swelling, infection, damage to adjacent teeth/restorations, delayed healing, dry socket, paresthesia (if applicable). Patient provided opportunity to ask questions. Verbal and written consent obtained." **Treatment** Local anaesthetic: [anaesthetic details] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Include the type, amount, and whether a vasoconstrictor was used.) [extraction details] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Describe the extraction performed, including the tooth number and instruments used such as forceps or elevators.) [socket management] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Include socket inspection, irrigation, and haemostasis method.) [complications] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Note any complications encountered during the procedure. If no complications occurred, state "No complications encountered.") **Post-Operative Instructions** [post-operative instructions] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Include whether verbal and written post-operative instructions were given to the patient.) [analgesia advice] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Include the analgesic recommended if discussed.) [follow-up] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Include the planned follow-up visit if discussed.) **Other Notes** [other notes] (Only include if explicitly mentioned in transcript, context or clinical note; else omit section entirely. Include any other information, advice, or discussions with the patient from the appointment.)