Adult Dental Examination

Seen by: [Clinician initials] Assisted by: [Assistant initials] Payment method: [Payment method] M/H: signed and updated today S/H: - Attends with: [describe presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Smoking: [Smoking status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Alcohol: [Alcohol consumption] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Recreational drugs: [Recreational drug use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Cessation advice: [Cessation advice given] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) D/H: - Toothbrush: [Toothbrush type] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Toothpaste: [Toothpaste type] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Interdental: [Interdental cleaning method] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Anxiety: [Anxiety related to dental visits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Attendance: [Attendance pattern] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) C/O: [Chief complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Examination (VCG given): E/O: Temporalis, TMJ, MoM, glands, nodes checked. Findings: [External examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) I/O Soft: Lips, buccal mucosa, gingiva, tongue, palate, FoM, tonsillar tissue checked. Findings: [Internal soft tissue findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) I/O Hard: - Oral hygiene: [Oral hygiene status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Occlusion: [Occlusion status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Stable ICP: [Stable ICP status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Lateral excursions: Group function / Canine guidance - Wear (where/type): [Wear details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Removable appliance: [Removable appliance details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Perio: - Estimated BOP: [Estimated BOP] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Furcation: [Furcation status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Recession: [Recession status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ORAL CANCER SCREEN: [Oral cancer screening results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Investigations: Last radiographs: [Date of last radiographs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Radiograph report Justification: assess caries, bone levels Type/grade: BWs L+R grade A Present: [Radiograph findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Caries: [Caries findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Restorations: [Restoration findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Endo: [Endodontic findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Bone levels: [Bone level findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Other: [Other findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) RISK: CARIES – [Caries risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) TSL – [Tooth surface loss risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PERIO – [Periodontal risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) SOFT TISSUE LESION – [Soft tissue lesion risk] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Diagnoses: [Diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Discussion/Prevention advice/treatment options: Treatment options explained, including how the treatment will be carried out, the risks and benefits of each option. Agreed upon Tx plan below VCG: Treatment plan (VCG): - Leave and monitor with prevention - Band 1 [Cost]: Prevention advice - OHI, Diet advice - Band 2 [Cost]: [Band 2 details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Band 3 [Cost]: [Band 3 details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Referral: [Referral details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Prevention advice given today. ** ** PREVENTION ADVICE PROMPTS (DBOH): OHI (guided by DBOH) - Brush 2x a day, once at bedtime and one other time - Use a smear (<3yrs) / pea sized amount (>3yrs) - Use a fluoride toothpaste with at least: 1000 ppm (less than 6), 1350-1500 ppm (>6) - Spit, don’t rinse - Highlighted target areas for patient - Sugar free medications Diet - Minimise sugar intakes - Avoid NME sugars - Do not eat anything after brushing on an evening - Had brief discussion of typical diet in a day and where to minimise sugar - Advised to avoid acidic food and drink to minimise wear - Do not eat 1 hour before brushing at bedtime Tx completed today: [Treatment completed today] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) NV: [Next visit details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, 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.)