Oral Surgery

Oral Surgery Consultation: Patient Name: [Patient’s full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date of Birth: [Patient’s date of birth] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Date of Consultation: [Date of the consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Referring Dentist: Name: [Referring dentist’s full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Practice: [Referring dentist’s practice name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Contact: [Referring dentist’s contact information] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Reason for Referral: [Detailed description of the reason for referral, including symptoms, concerns, or prior diagnoses discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medical History: [Summary of past and current medical conditions, including relevant chronic or acute conditions and family history if stated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medications: - [List of current medications including prescription, over-the-counter, supplements, and dosages] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Known drug allergies and reactions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Dental History: [Relevant dental history including prior procedures, extractions, orthodontics, periodontal disease, trauma, or ongoing concerns] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Social History: Smoking Status: [Current or past smoking history including type, quantity, and duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Alcohol Consumption: [Alcohol intake including frequency and quantity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Other Recreational Drug Use: [Any other recreational drug use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Occupation: [Patient’s occupation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Living Situation: [Patient’s living arrangements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Clinical Examination Findings: Extra-Oral Examination: [Findings including facial symmetry, lymph nodes, TMJ assessment, or external abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Intra-Oral Examination: [Findings including soft tissues, dentition, periodontal status, occlusion, or mucosal abnormalities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Specific Area of Concern: [Findings related to the referred tooth, lesion, or anatomical area] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Radiographic Findings: [Interpretation of any imaging reviewed, including type of imaging and relevant findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Diagnosis: [Formal diagnosis or differential diagnoses stated by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Do not invent or infer a diagnosis.) Discussion with Patient: [Summary of discussion regarding condition, treatment options, risks, benefits, alternatives, and patient questions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Treatment Plan: - [Proposed treatment plan including procedures, peri-operative instructions, and follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Referrals to other specialists if stated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Informed consent discussion and confirmation of agreement] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Prognosis: [Anticipated outcome or long-term outlook discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Next Steps: [Next actions such as scheduling surgery, investigations, or follow-up appointments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)