Oral/Dental Hygienist Template
Dental Hygiene Assessment and Treatment Note
A professional Oral/Dental Hygienist template for healthcare professionals.
About this template
Streamline your dental hygiene documentation with this comprehensive Dental Hygiene Assessment and Treatment Note template. Specifically designed for Oral/Dental Hygienists, this template ensures all crucial aspects of a patient's visit are meticulously recorded, from chief complaints and medical history to detailed intraoral examinations and periodontal assessments. It guides you through documenting diagnoses, treatment plans, and oral health education, ensuring thorough and consistent patient records. Utilising this template with Heidi, our AI medical scribe, means a highly accurate and structured note is generated from your conversations, capturing specific details like BPE scores and individual oral hygiene routines. Perfect for maintaining high standards in patient care and practice efficiency, this template supports best practices in dental record-keeping.
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Reason for Attendance:
Hygiene visit
Chief Complaint:
- Patient concerned about gum bleeding
- Wants whiter teeth
Medical History:
- Medications: None reported
- Allergies: Penicillin (rash)
Past Dental History:
Regular dental attendance, last check-up 6 months ago.
Social History:
- Smoking status: Non-smoker
- Alcohol consumption: Occasional, 2-3 units per week
Oral Hygiene Regime:
- Brushing: Manual toothbrush twice daily, 2 minutes each time
- Interdental cleaning: Dental floss occasionally, no interdental brushes
Extraoral Examination:
NAD
Intraoral Examination:
- Soft tissues: Healthy mucosa, no pathology noted
- Hard tissues: No active caries detected, several old amalgam restorations, one composite restoration on UR6
- Gingival appearance: Mild inflammation, localised redness on lower anterior sextant
- Soft deposits: Moderate plaque accumulation throughout, particularly on lingual surfaces of lower anterior teeth
- Hard deposits: Moderate calculus on lingual surfaces of lower anterior teeth, slight supra-gingival calculus elsewhere
- Oral hygiene: Fair
- Bleeding on probing: Present in lower anterior sextant, localised in upper posterior sextant
- Recession: UR3 (1mm), LL1 (1mm)
- Mobility: No mobility detected
- Furcation: No furcation involvement detected
Periodontal Assessment:
BPE Scores:
Upper Right: 2
Upper Left: 2
Lower Right: 3
Lower Left: 3
Pocket chart:
Lower Right Sextant: LL4: 4mm, LL5: 4mm, LL6: 3mm
Lower Left Sextant: LR4: 4mm, LR5: 4mm, LR6: 3mm
Diagnosis:
- Localised gingivitis
- Chronic periodontitis (Stage I, Grade A) in lower anterior region
Discussion:
- Explained findings of gingivitis and localised periodontitis.
- Discussed importance of effective plaque control.
- Advised on appropriate brushing technique and interdental cleaning.
- Explained planned treatment of scaling and polishing.
- Patient expressed understanding and consented to treatment.
Treatment Provided:
PMPR - Full mouth supra- and sub-gingival scaling using ultrasonic scaler and hand instruments, followed by polishing with prophylactic paste.
Oral Health Education:
- Demonstrated modified Bass technique for toothbrushing.
- Recommended daily use of interdental brushes for lower anterior teeth.
- Advised on use of fluoride toothpaste.
Recall:
3-month recall for review and further periodontal assessment due to localised periodontitis and gingivitis.
Clinician:
Ms. Eleanor Vance
Registered Dental Hygienist
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