No clinical note, not a bad or incomplete note, is the most common issue resulting in headaches for dentists, billing staff and other sttakeholders.
Adequate documentation to explain who, what, why, and how is essential.
Document like you wrote in dental school, but in a fraction of the time.
Our collection of about 50 + templates will save you time, $ and headaches when your records are scrutinized by 3rd parties (a certainty in today’s insurance and regulatory environments).
The templates are easy to upload to Open Dental, Eaglesoft and other software. Dentrix users will need to build these templates into their systems, which is not hard – it’s just not as simple as Open Dental or Eaglesoft.
- Oral Surgery
Sample Template - Extraction
Pt presents for extraction of tooth _____ due to; diagnosis:____
RMHX: No changes from medical history recorded on (enter date of previous medical history update):
Time Out Procedure Performed Prior to Extraction. Verified informed consent was signed by patient/ caregiver.
___ Tooth is non-restorable due to caries
___ Tooth is non-restorable due to the extent of fractured off tooth structure
___ Pulpal and/or periapical pathology that cannot be treated
___ Pathological cyst formation
___ Second or subsequent episodes of pericoronitis (unless the first episode is particularly severe), that cannot be resolved through the use of antibiotics, irrigations, or other topical treatment
___ Tumor removal that also requires removal of tooth for access
___ Tooth is positioned ectopically and prevents the eruption of an adjacent tooth
___ Internal/external resorption of a tooth or adjacent tooth
___ Tooth in aberrant position that is causing bone loss on adjacent tooth/teeth
___ Tooth/teeth impeding orthognathic surgery, reconstructive surgery, trauma surgery, or other jaw surgery
___ exfoliation not imminent
___ have x-ray showing clearly the adjacent and opposing teeth
___ bicuspid extraction(s) for orthodontic care
Anes: ___ carp 4% citanest plain; ___ carp infiltrate of 4% sept with 1/100k epi and ___ carp 2 lido with 1/100k epi
Elevated flap, sectioned tooth # ___ and/or removed bond.
Elevated and extracted tooth #___ without complication; placed digital pressure, irrigated with sterile saline; hemostasis achieved
Oral and written post-op instructions given written
Extraction: Complete / Incomplete
Pt tolerated the procedure well, instructed to call or return to the office if any concerns or complications
NEXT VISIT --
Assisted by/ Notes completed by: (insert full name and title here)
Reviewed and approved by Dr. (Insert Name of Dentist)