Dental Hygiene Assessment and Treatment Note

Reason for Attendance: [Reason for the current visit] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If no reason is mentioned, write: "Hygiene visit". Write on a single line.) Chief Complaint: [Patient's main concerns and reason for visit 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 each concern on a new line.) Medical History: [Patient's current medication status and known drug allergies] (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.) Past Dental History: [Patient's dental attendance history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) Social History: [Patient's smoking status and alcohol consumption habits] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with smoking status on one line and alcohol consumption on the next.) Oral Hygiene Regime: [Patient's toothbrushing routine and interdental cleaning habits including any aids used] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with brushing details on one line and interdental cleaning details on the next.) Extraoral Examination: [Findings from the extraoral examination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else write: "NAD". Write on a single line.) Intraoral Examination: [Findings from the intraoral examination across soft tissues, hard tissues, gingival appearance, soft deposits, hard deposits, oral hygiene, bleeding on probing, recession, mobility and furcation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each finding category on a new line labelled with its category name.) Periodontal Assessment: [BPE scores and pocket chart readings where relevant] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If BPE scores of 3 or 4 are explicitly mentioned for any sextant, include the pocket chart findings for those sextants. If BPE scores do not reach 3 or 4, write: "Pocket chart: Not required". Write as a list with BPE scores on one line and pocket chart findings on the next.) Diagnosis: [Clinician's explicitly stated clinical 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.) Discussion: [Summary of the discussion held with the patient regarding findings, diagnosis and proposed treatment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each point on a new line.) Treatment Provided: [Description of the treatment carried out during the visit including specific modalities used and the order in which they were performed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If a PMPR was performed, begin with "PMPR" and list the specific modalities in the order performed. If no specific modalities are mentioned but a PMPR was performed, write: "PMPR". Write as a single line.) Oral Health Education: [Oral health education and advice provided to the patient during the visit] (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.) Recall: [Recommended recall interval and rationale] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write on a single line.) Clinician: [Clinician name and professional title] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write the name on one line and the professional title on the next.)