Pre-Operative Assessment:
Medical and Dental History: The patient has a history of mild dental anxiety and has undergone previous extractions without complications. No bleeding disorders or anticoagulant use were reported.
Tooth Assessment and Diagnosis: Examination and radiographs revealed that tooth number 36 was severely decayed with signs of infection and moderate mobility. The root anatomy appeared normal with no significant bone involvement.
Consent Documentation: "Verbal and/or written consent was obtained from the patient and/or guardian prior to extraction. The procedure, risks, benefits and alternatives were discussed."
Anaesthesia:
Type of Anaesthetic Used: Lidocaine 2% with epinephrine 1:100,000 was administered via local infiltration.
Onset and Effectiveness: Anaesthesia took effect within 5 minutes, providing adequate numbness for the extraction procedure.
Extraction Procedure:
Tooth/Teeth Extracted: Tooth number 36 was extracted using the Universal system.
Technique Used: A simple extraction technique was employed.
Instruments and Materials Used: Forceps and elevators were used during the extraction.
Intraoperative Observations: No granulation tissue or cystic changes were observed. The extraction was uncomplicated.
Complications (if any): No complications were noted during the procedure.
Post-Extraction Management:
Haemostasis Achieved: Haemostasis was achieved using gauze pressure.
Post-Operative Instructions Given: The patient was advised to apply pressure with gauze for 30 minutes to control bleeding, avoid rinsing or spitting for 24 hours, and maintain a soft diet. Pain management with over-the-counter analgesics was recommended, and the patient was instructed to contact the clinic if excessive bleeding or pain occurred.
Medications Prescribed (if any): Ibuprofen 400 mg was prescribed for pain management.
Follow-Up Plan: The patient was advised to return for a follow-up appointment in one week to assess healing.
Provider Details:
Dentist Name and Credentials: Dr. Emily Carter, DDS
Dental Assistant (if applicable): Sarah Johnson, Dental Assistant
Pre-Operative Assessment:
Medical and Dental History: [insert relevant medical and dental history including bleeding disorders, anticoagulant use, history of infection, dental anxiety, or prior extractions] (only include relevant history if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a full paragraph in complete sentences.)
Tooth Assessment and Diagnosis: [insert findings from examination and any radiographs including tooth number, condition of the tooth, presence of infection, mobility, root anatomy, or bone involvement] (only include findings if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a full paragraph.)
Consent Documentation: "Verbal and/or written consent was obtained from the patient and/or guardian prior to extraction. The procedure, risks, benefits and alternatives were discussed."
Anaesthesia:
Type of Anaesthetic Used: [insert type of anaesthetic agent, dosage, concentration, and method of delivery] (only include anaesthetic details if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write in a sentence.)
Onset and Effectiveness: [insert observations on how quickly anaesthesia took effect and the adequacy of numbness achieved before extraction] (only include onset and effectiveness if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a short paragraph.)
Extraction Procedure:
Tooth/Teeth Extracted: [insert the tooth number(s) extracted using FDI, Palmer, or Universal system as applicable] (only include tooth numbers if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Technique Used: [insert whether extraction was simple, surgical, or required sectioning or flap elevation] (only include extraction technique if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a sentence.)
Instruments and Materials Used: [insert list of dental instruments used during the extraction such as forceps, elevators, scalpel, sutures, or curettes] (only include instruments or materials used if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. List in a sentence.)
Intraoperative Observations: [insert any findings such as granulation tissue, cystic changes, ankylosis, or root fracture observed during the extraction] (only include intraoperative findings if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as full sentences.)
Complications (if any): [insert any complications such as root fracture, excessive bleeding, sinus perforation, or difficulty in extraction] (only include complications if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a paragraph.)
Post-Extraction Management:
Haemostasis Achieved: [insert method used to achieve haemostasis, including gauze pressure, sutures, or haemostatic agents] (only include haemostasis method if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write in sentence format.)
Post-Operative Instructions Given: [insert instructions provided regarding bleeding control, pain management, oral hygiene, activity restrictions, diet, and what to do if complications arise] (only include post-operative instructions if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a full paragraph.)
Medications Prescribed (if any): [insert medications prescribed such as analgesics, antibiotics, or antiseptic rinses] (only include medications if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. List in a sentence.)
Follow-Up Plan: [insert any advice regarding review appointments, suture removal, or further treatment required] (only include follow-up plan if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Write as a sentence.)
Provider Details:
Dentist Name and Credentials: [insert full name and professional designation of the clinician performing the extraction] (only include clinician information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Dental Assistant (if applicable): [insert name and role of dental assistant present during the procedure] (only include assistant information if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(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.)
