Dental Examination and Hygiene Note

(Write all content in systematic order. If a finding is normal or not applicable, state "NAD", "-ve", or "n/a" as appropriate for the context, otherwise provide specific clinical details.) Examination and Hygiene: [Confirmation that the patient was made aware they are seeing a Dental Therapist and that the scope of practice was explained] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If explicitly mentioned, print: "Made patient aware they are seeing a Dental Therapist today - scope explained - out of scope referrals will be made appropriately". Write on a single line.) Medical History: [Confirmation that medical history was checked and updated] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If explicitly mentioned, print: "Checked and updated". Write on a single line.) Presenting Complaint: [Patient complaints and cosmetic concerns as described by the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with patient complaints on one line labelled "Pt c/o" and cosmetic concerns on the next line labelled "Cosmetic concerns".) Past Dental History: [Dental attendance pattern, date of last dental visit and date of last hygiene visit] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with attendance pattern on one line, last dental visit labelled "LDV" on the next line and last hygiene visit labelled "LHV" on the following line.) Social History: [Smoking status, alcohol consumption, sugar intake, acidic diet and stress levels] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line labelled with its category name. If smoking is mentioned, include cessation discussion details and risks for periodontal disease and oral cancer. If alcohol is mentioned, include consumption level as low, moderate or high, risks discussed and advice given. If sugar intake is mentioned, include consumption level as low, moderate or high and advice given to reduce intake and keep to mealtimes. If acidic diet is mentioned, include assessment findings and recommendations given. If stress is mentioned, include the assessment findings.) Oral Hygiene Regime: [Brushing frequency, interdental cleaning details, fluoride use and mouthwash use] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line labelled with its category name. If brushing is mentioned, state frequency as number of times per day. If fluoride is mentioned and used, include toothpaste details. If fluoride is not mentioned, print: "No". Write brushing on one line labelled "Brushing", interdental cleaning labelled "IDC", fluoride labelled "Fluoride" and mouthwash labelled "MW".) "Protective glasses given to patient" Extraoral Examination: [Findings from the extraoral examination across face, head, TMJ, neck, lymphadenopathy, mouth opening measurement and bruxism awareness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD" for each sub-item not mentioned. Write as a list with each finding on a new line labelled as Face/head, TMJ, Neck, Lymphadenopathy, MOM and bruxism awareness respectively.) Intraoral Examination: [Findings from the soft tissue examination including tongue, palate, floor of mouth, buccal mucosa, buccal sulcus and lips, and oral cancer screening result] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD" for soft tissues and "-ve" for oral cancer screen. Write as a list with soft tissue findings labelled "Soft Tissues" and oral cancer screen result labelled "Oral cancer screen" each on a new line.) Hard Tissues: [Findings from the hard tissue examination including caries, defective fillings, abnormalities, teeth to watch, other findings, extra coronal restorations and removable prosthetics] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely for caries, defective fillings, abnormalities, teeth to watch and other findings, and write: "n/a" for extra coronal restorations and removable prosthetics. Write as a list with each finding on a new line labelled as Caries, Defective fills, Abnormalities, Teeth to watch, Other findings, Extra coronal restorations and Removable prosthetics respectively. Begin with "Dentition as charted" on the first line if dentition charting is mentioned.) Occlusion: [Incisal classification, lateral excursion, parafunctional activity and other occlusal findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each finding on a new line labelled as Incisal classification, Lateral excursion, Parafunction and Other respectively.) Tooth Surface Loss: [BEWE score and type of tooth surface loss] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with BEWE score labelled "BEWE" and type of tooth surface loss labelled "Type" each on a new line.) Periodontal Assessment: [BPE scores, periodontal chart reference, gingival appearance, deposits, oral hygiene status, recession, mobility and furcation involvement] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each finding on a new line labelled as BPE, Perio Chart, Gingival appearance, Deposits, OH status, Recession, Mobility and Furcation respectively.) Radiographs: [Type of radiographs taken, justification, radiographic grade, alveolar bone levels, caries findings and pathological findings from radiographs] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each item on a new line labelled as Radiographs Taken, Justification, Grade, Alveolar bone levels, Caries and Pathology respectively. If different radiograph options were discussed, list each option on a new line labelled as Bitewings, Periapicals or OPG with the justification for each.) Sensibility / Vitality Testing: [Teeth tested, method used and result of sensibility or vitality testing] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with teeth tested labelled "Teeth tested", method labelled "Method" and result labelled "Result" each on a new line.) [Confirmation that photos were taken] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If explicitly mentioned, print: "Photos taken". Write on a single line.) [Confirmation that an iTero scan was recorded] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If explicitly mentioned, print: "Itero scan recorded". Write on a single line.) Clinical Diagnosis: [Clinician's explicitly stated primary and secondary diagnoses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write as a list with one diagnosis per line.) Risk Classification: [Clinician's explicitly stated risk classification for oral cancer, periodontal disease, caries and tooth surface loss] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each risk on a new line labelled as Oral cancer risk, Perio risk, Caries risk and TSL risk respectively.) Discussion of Options: Gingival Health: [Clinician's explicitly stated gingival health status and summary of discussion with the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. If the clinician explicitly states gingival health is healthy, print: "Healthy - OH efforts good and sustainable for health, minimal personalised OHI required and given". If the clinician explicitly states gingivitis is present, print: "Gingivitis - gingival inflammation present, advised this is reversible, personalised OHI given, advised continued inflammation can lead to permanent damage to the periodontium and progression into periodontitis which is irreversible". If the clinician explicitly states periodontitis is present, print: "Periodontitis - advised patient has irreversible damage to their periodontium, notified patient we cannot regrow lost bone to levels in line with health, the aim now is to prevent progression and retain as much bone surrounding the affected teeth as possible, OHI given". Write on a single line.) [Whether further hygiene treatment is required] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line labelled "Further hygiene treatment required".) [Treatment options discussed for each tooth mentioned] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. For each tooth discussed, write the tooth number as a heading using the notation mentioned, then list each option on a new line beginning with the option number in square brackets. Always include option 1 as "Leave". Include subsequent options only if explicitly mentioned. After the options list, print: "Pros / Cons of each option including fees discussed verbally". Then state the option the patient chose on a new line beginning with "Pt has opted for option" followed by the chosen option number.) Treatment Completed Today: "[1] Exam and any required investigations" "[2] f/m PMPR using airpolishing w/ erytritol powder and USS" [3] [Oral health instruction provided during the visit] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit this line. Write on a single line beginning with "[3] OHI -" followed by the instruction provided.) Treatment Required: [Items of treatment required following today's visit] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a numbered list with each treatment item on a new line.) Referrals: [Referral details including the clinician referred to and the reason for referral] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "N/A". Write on a single line.) Recall: [Examination recall interval in months as agreed with the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit this line. Print: "SDCEP & NICE guidelines reviewed and agreed Examination recall of: " followed by the recall interval in months followed by "/ 12". Write on a single line.) [Hygiene recall interval in months as agreed with the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit this line. Print: "SDCEP & BSP guidelines reviewed and agreed Hygiene recall of: " followed by the recall interval in months followed by "/ 12". Write on a single line.) Therapist: [Therapist name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) Nurse: [Nurse name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) [Confirmation that a treatment plan and next appointment were arranged] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If explicitly mentioned, print: "TC / TCA Tx". Write on a single line.)