Dental Examination Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Dental Note Template

Chief Complaint:
[Patient's stated reason for visit]

History of Present Illness:
[Description of onset, duration, location, and character of dental symptoms]
[Associated symptoms such as pain, swelling, bleeding, sensitivity]
[Aggravating or relieving factors]
[Previous dental treatments related to current complaint]

Past Dental History:
(hyphenated list)
- [Previous dental procedures]
- [History of dental trauma]
- [Orthodontic treatment]
- [Periodontal disease]
- [Other relevant dental history]

Medical History:
(hyphenated list)
- [Chronic medical conditions]
- [Recent hospitalizations or surgeries]
- [Relevant systemic diseases]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug allergies]
- [Latex allergy]
- [Other relevant allergies]

Social History:
(hyphenated list)
- [Tobacco use: type, amount, duration]
- [Alcohol use: type, amount, frequency]
- [Recreational drug use]
- [Occupation]
- [Living situation]

Dental Examination:
(hyphenated list)
- [Vital signs if taken: HR: #, BP: #, T: #, RR: #, O2 sats: #%]
- [Extraoral exam: findings]
- [Intraoral soft tissue exam: findings]
- [Teeth: findings by tooth number or region]
- [Periodontal exam: probing depths, bleeding, recession]
- [Occlusion: findings]
- [Radiographic findings if available]

Investigations:
(hyphenated list)
- [Radiographs: type and findings]
- [Other diagnostic tests]

Assessment:
(hyphenated list)
- [Primary dental diagnosis]
- [Secondary diagnoses]
- [Differential diagnosis if applicable]

Plan:
(hyphenated list)
- [Immediate treatment provided]
- [Planned procedures]
- [Medications prescribed]
- [Patient education and counselling]
- [Referrals to specialists]
- [Follow up plan]
- [Return precautions]