Prosthodontist Template

Prosthodontist's note (custom)

A professional Prosthodontist template for healthcare professionals.

About this template

This Prosthodontist's note template is designed for dental professionals specializing in prosthodontics to document comprehensive patient evaluations. It includes sections for chief complaints, detailed history, past dental and medical history, and examination findings. The template also covers radiographic findings, diagnoses, prognosis, and treatment plans. Ideal for prosthodontists, this template ensures thorough documentation of patient visits, aiding in effective treatment planning and follow-up care. Use this template with Heidi, the AI medical scribe, to streamline your documentation process and maintain high-quality patient records.

Preview template

Chief Complaint: - Patient presents with difficulty chewing and discomfort in the upper jaw for the past 3 months. History of Presenting Complaints: - The patient reports a gradual onset of discomfort in the upper jaw, which has progressively worsened over the last 3 months. The discomfort is aggravated by chewing hard foods and alleviated by resting the jaw. The patient also notes occasional swelling in the area. - The patient expresses concern about the appearance of their smile due to missing teeth. Past Dental History: - The patient had a root canal treatment on the lower right molar in 2020, which was successful. - Extraction of the upper left second molar in 2018 due to severe decay. Past Medical History: - The patient has a history of hypertension, managed with medication. - No known allergies. Personal History: - The patient brushes twice daily and uses dental floss regularly. - Reports occasional teeth grinding at night. Family History: - The patient's mother had a history of periodontal disease. Extra Oral Examination: - No significant findings in lymph node examination. - Facial symmetry is normal. Intra Oral Examination: - Soft tissue examination reveals healthy buccal mucosa and tongue. - Gingival examination shows mild gingivitis with slight bleeding on probing. - Hard tissue examination reveals missing upper left second molar and moderate dental caries on the upper right first molar. - Oral hygiene status is fair based on the OHI index. - Occlusion analysis indicates a Class I occlusion with mild crowding in the lower anterior teeth. Radiographic Findings: - Panoramic radiograph shows moderate bone loss around the upper right first molar and caries in the same tooth. Diagnoses: - Partial edentulism in the upper jaw. - Moderate dental caries on the upper right first molar. Prognosis: - Overall prognosis is good with appropriate treatment. - The upper right first molar has a fair prognosis due to caries and bone loss. Treatment: - Recommend a fixed partial denture to replace missing teeth in the upper jaw. - Restoration of the upper right first molar with a composite filling. - Preventative plan includes reinforcing oral hygiene practices and regular dental check-ups every 6 months. - Follow-up appointment scheduled for 15 November 2024.

Chief Complaint: - [Detail the chief complaint or primary reason for presentation along with duration.] (Only include chief complaint if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) History of Presenting Complaints: - [Provide a detailed description of all complaints one-by-one, including onset, progression, aggravating or alleviating factors, associated symptoms, duration, intensity, nature, frequency of symptoms, etc.] (Only include detailed description of complaint(s) if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Include description of any cosmetic concerns.] (Only include cosmetic concerns if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) Past Dental History: - [Mention any previous dental treatments, surgeries, significant dental diseases, or injuries, including dates and outcomes.] (Only include previous dental treatments, surgeries, significant diseases, or injuries if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) Past Medical History: - [List any known medical conditions, previous surgeries, hospitalizations, ongoing treatments, allergies, and medications being taken.] (Only include medical conditions, surgeries, hospitalizations, ongoing treatments, allergies, or medications if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Personal History: - [Mention patient's past oral hygiene practices.] (Only include oral hygiene practices if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) - [Mention any habits with a focus on dentition such as clenching, grinding, biting, tobacco chewing, smoking, or alcohol intake.] (Only include habit history if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Family History: - [Mention family history including any relevant genetic or familial diseases, especially those related to dental or systemic health.] (Only include family history if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Extra Oral 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.] (Only include extra-oral examination findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Intra Oral Examination: - [Mention/describe any soft tissue examination findings, including findings on buccal mucosa, tongue, palate, floor of the mouth, vestibule, etc.] (Only include soft tissue findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Mention/describe any gingival examination findings, including color, 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, otherwise omit completely.) - [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, otherwise omit completely.) - [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, otherwise omit completely.) - [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, otherwise omit completely.) - [Mention/describe any other intra-oral examination findings.] (Only include other intra-oral findings if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) Radiographic Findings: - [Describe radiographic 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, otherwise omit completely.) Laboratory Investigations: - [Mention/list any investigations, along with results, such as blood counts, hemoglobin, platelet count, bleeding time, clotting time, ESR, blood sugar, etc., including dates where possible] (Only include investigation results and dates if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) - [Mention any biopsy findings.] (Only include biopsy findings if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Diagnoses: - [List/mention diagnoses one-by-one.] (Only include diagnoses if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely.) Prognosis: - [Describe any overall prognosis.] (Only include overall prognosis if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own prognosis or evaluation.) - [Describe any individual prognosis for teeth at risk.] (Only include individual prognosis for teeth at risk if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own prognosis or evaluation.) Treatment: - [List and describe treatment plans/recommendations one-by-one.] (Only include treatment plans/recommendations if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own treatment plans.) - [List and describe preventative plans such as oral hygiene recommendations, etc., one-by-one.] (Only include preventative plans if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own preventative plans.) - [Mention review date or follow-up plans.] (Only include review date or follow-up plans if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise omit completely. Never come up with your own review or follow-up plans.) (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.)

Browse more templates

Use this template