011, comprehensive exam

General Instructions: (Use FDI notation for all teeth. Do not use any other notation such as UR1.) (When documenting, use phrasing such as "patient opted" rather than "dentist recommended.") Medical History: [confirmation that medical history was checked and updated] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Presenting: [patient full name] arrived for comprehensive exam (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [who is attending with the patient and their relationship/profession if applicable] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) WKY: [hobbies, occupation, work, interests, family, country of origin, and family members present at appointment] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Relevant Medical History: [relevant systemic medical history] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Main Concern: [main reason for visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Dental and Social History: Brushing: [brushing frequency, toothpaste used, toothbrush type] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Interdental Cleaning: [interdental cleaning method such as floss, pikster, flossettes, toothpicks, water flosser] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Diet: [frequency and type of snacking, soft drinks, energy drinks, coffee, tea consumption] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Water: [water consumption rated as poor, fair, good, or excellent] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Sleep Quality: [sleep quality, average hours, jaw tenderness on waking if present] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Last Dental Visit: [date and type of last dental visit] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Trauma History: [any history of dental or maxillofacial trauma] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Smoking Status: [smoking status and amount] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Extra-Oral Examination: [findings from extra-oral exam, or NAD if none noted] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Intra-Oral Examination: Soft Tissue: [findings on tongue, cheeks, palate, other oral soft tissues, or NAD] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Oral Cancer Screening: [suspicious lesions noted or NAD] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Dentition and Caries Charting: [findings including missing teeth, surfaces affected, lesions, structural/endodontic/periodontal/functional status, mobility] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) PSR: [periodontal screening result in format XXX, XXX] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Plaque: [plaque level graded as +, ++, +++] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Calculus: [calculus level graded as +, ++, +++] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) NCTL: [non-carious tooth loss with grading (mild/moderate/severe) and type (attrition, abrasion, erosion, abfraction)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Occlusion: [type of occlusion] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Overbite: [percentage value] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Overjet: [length in mm] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Crowding: [grade of crowding: mild, moderate, severe] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Other: [other intraoral findings not covered above] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Imaging: [intraoral photographs taken] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [iTero scan taken] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [Diagnocam imaging taken] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Radiographic Findings: [type of radiographs taken e.g. OPG, CBCT, bitewings, PA] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [radiographic findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Problem List / Diagnoses: [list objective problems, issues, and diagnoses] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Discussion and Treatment Options: [discussion of each problem/diagnosis with patient, listed in same order as Problem List/Diagnoses] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [statement that patient opted to proceed with the plan below] (Always include once treatment options are discussed.) Treatment Plan: [ordered treatment plan including today’s appointment and follow-ups, in numerical order with time intervals noted. Always end with 6/12 with OHT] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) Post-Operative Instructions: NV: [next visit details including appointment type, duration, and reason] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) RTR: [reason for return explained in simple, patient-friendly language without jargon] (Only include if explicitly mentioned in transcript or context, else omit section entirely.) [patient first name] well on discharge (Only include if explicitly mentioned in transcript or context, else omit section entirely.) - Sari (Always include) Additional Information: [any other relevant information not captured above] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note.)