Practitioner Details:
[Enter full name include prefix and role of clinician]
Type of Examination Conducted:
[Describe the type of examination conducted and specify if consent was obtained] (only include if explicitly mentioned in the transcript, contextual notes or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Presenting Complaint:
[Describe presenting complaint in the patient’s own words] (only include presenting complaint if explicitly mentioned in the transcript, contextual notes or clinical note, If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Dental History:[Describe relevant dental history, including previous treatments, last dental review and dental habits] (only include if explicitly mentioned in the transcript, contextual notes or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Medical History:[Describe relevant medical history and surgical history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Social History:[Describe relevant social history including smoking status, drug and alcohol use, work or study details] (only include social history if explicitly mentioned in the transcript, contextual notes or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Medications: [List any medications patient is taking, including over the counter and herbal supplements] (Only include medication history if explicitly stated in the transcript, contextual notes or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Allergies: [List any allergies to medications, latex, food or other]. (only include if explicitly mentioned in the transcript, contextual notes or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Clinical Findings and Observations:
E/O Examination: [Mention/describe any extra-oral examination findings such as lymph node examination, facial symmetry, TMJ examination (e.g., 3-finger mouth opening test), lips, etc.] (E/O stands for extra-oral in this section. Only include extra-oral examination findings if explicitly mentioned in the transcript, contextual notes, or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
I/O Examination:
Soft-tissue examination: [Mention/describe any soft tissue examination findings, including soft tissue examination findings on buccal mucosa, tongue, palate, floor of the mouth, vestibule, etc.] (I/O stands for intra-oral in this section. Only include soft tissue examination findings if explicitly mentioned in the transcript, contextual notes, or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Oral cancer screen (FoM, palate, pharynx, soft tissues: [Mention/describe any findings suspicious for oral cancer, if none specify 'NAD'](Only include oral cancer screen if explicitly mentioned in the transcript, contextual notes, or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Gingiva: [Mention/describe any gingival examination findings, including colour, contour, size, consistency, surface texture, position, bleeding position, exudation, amount of attached gingiva, gingival tension test, etc.] (Only include gingival findings if explicitly mentioned in the transcript, contextual notes, or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Hard tissue examination: [Mention/describe any hard tissue examination findings, including number of teeth present, missing teeth, dental caries, restored teeth, periapical problems, pathologic migration, overhanging restorations, impacted teeth, supernumerary teeth, wasting diseases (attrition/abrasion/erosion/abfraction), mobility grading, shade analysis, stains/deposits, etc.] (Only include hard tissue findings if explicitly mentioned in the transcript, contextual notes, or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Oral Hygiene Status:[Mention any findings on oral hygiene status, e.g., good/fair/poor based on OHI index, etc.] (Only include oral hygiene findings if explicitly mentioned in the transcript, contextual notes, or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Occlusion analysis:[Mention/describe any occlusion analysis findings, such as type of occlusion (Angles classification, etc.), overbite, overjet, crossbite, open contacts, crowding, facets, supra contacts, trauma from occlusion, Fremitus test, etc.] (Only include occlusion analysis findings if explicitly mentioned in the transcript, contextual notes, or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Other I/O findings: [Mention/describe any other intra-oral examination findings not captured in the previous sections.] (Only include other intra-oral findings if explicitly mentioned in the transcript, contextual notes, or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Radiographic Findings:
[Describe which radiographs have been taken, whether the patient was consented for them, whether they were taken today or from a previous consultation. Specify findings from dental radiographs, noting any pathologies like caries, cysts, tumors, tooth positions, bone levels, etc., and mention comparisons with previous radiographs.] (Only include radiographic findings if explicitly mentioned in the transcript, contextual notes, or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
[Mention/list any investigations, along with results, such as blood counts, hemoglobin, platelet count, bleeding time, clotting time, ESR, blood sugar, etc., include dates where possible] (Only include investigation results and dates if explicitly mentioned in the transcript, contextual notes, or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
[Mention any biopsy findings.] (Only include biopsy findings if explicitly mentioned in the transcript, contextual notes, or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Diagnosis:
[Provide the primary diagnosis and any differential diagnoses for the patient's condition] (only include diagnosis if explicitly mentioned in the transcript, contextual notes or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A. Never come up with your own diagnosis.)
Treatment Options discussion:
[Outline treatment options discussion including risks, benefits, and alternatives discussed with the patient. Including rough cost for each treatment discussed if available.] (only include treatment options discussed if explicitly mentioned in the transcript, contextual notes or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A Never come up with your own treatment options.)
[Include patient questions, concerns, and their decisions about the treatment plan] (only include patient questions if explicitly mentioned in the transcript, contextual notes or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Proposed Treatment Plan: [Outline the proposed treatment plan, including any discussion on risks, benefits, alternatives and patient questions.] (only include proposed treatment plan if explicitly mentioned in the transcript, contextual notes or clinical note. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A. Never come up with your own treatment plan. )
Consent:
[Document patient consent for proposed treatment(s) and procedures] (only include if explicitly mentioned in the transcript or contextual notes provided. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Procedures Conducted:
[Detail the procedures performed during the visit, including steps and instruments used in detail] (only include procedural information if explicitly mentioned in the transcript or contextual notes provided. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Instrument Tracking:
[Enter instrument batch control identification numbers] (only include instrument tracking if explicitly mentioned in the transcript or contextual notes provided. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
[Coding of the dental service/s provided](only include coding details if explicitly mentioned in the transcript or contextual notes provided. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Medications/Therapeutics:
[List any medicines or therapeutic agents prescribed, administered, or supplied during the consultation, including name, quantity, dose, and instructions] (only include medications and therapeutics if explicitly mentioned in the transcript or contextual notes provided. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Advice Provided:
[Summarise advice given to the patient, including oral hygiene instructions and follow-up care. Include fee estimates or signed quotations if applicable.] (only include advice given to the patient if explicitly mentioned in the transcript or contextual notes provided. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Follow-Up and Referrals:
[Detail any referrals made or received, including follow-up instructions and communications. Include fee estimates or signed quotations if applicable to follow up appointments.] (only include follow up and referrals iformation if explicitly mentioned in the transcript or contextual notes provided. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Unusual Events:
- [Document unusual sequelae of treatment, significant events, or adverse outcomes.] (only include unusual events if explicitly mentioned in the transcript or contextual notes provided. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Additional Digital and Laboratory Information:
[Include any additional digital information including CAD/CAM records, instructions to laboratories, and communications] (only include additional digital and lab information if explicitly mentioned in the transcript or contextual notes provided. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Final Notes:
[Include a summary of the treatment provided and discussions about future treatments or advice. Include any final observations or clinician's notes about the session.] (only include if explicitly mentioned in the transcript or contextual notes provided. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
Other Details:
[Enter details of substitute decision-makers or changes to consent arrangements, if applicable] (only include other details if explicitly mentioned in the transcript or contextual notes provided. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
[Document patient failure to attend and follow-up actions taken] (Only include this information if explicitly mentioned in the transcript or contextual notes provided. If normal or no abnormalities are detected, write NAD. If not mentioned write N/A.)
(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 included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs, or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
[Document if patient consent was given]
