Default CliniCal note templates

1 Default CliniCal note templatesThe following is a list of all the Default CliniCal note templates that are included with Dentrix. Unless you have previously customized your CliniCal note templates , your database should include these Default templates . The list is broken down by category. Within each category, the template name and note text for each Default template is listed. Some templates include note prompts that prompt the user to answer a question or enter information; the prompts are enclosed in parentheses and : administrativeTemplate NameNote TextCancelled Appt <24-Hr NoticeThe patient cancelled their appointment with less than 24-hour DismissedThe patient was dismissed from the practice because of (Patient Dismissal Reason). The patient was given 30-days notice prior to dismissal from the practice, and told that the practice is still available for emergency treatment for the next 30 days while the patient is seeking another Failed Confirmed ApptThe patient s appointment was previously confirmed, and the patient did not arrive at the office for their scheduled AppointmentThe patient (Return Appointment) to finish : anesthetiCsTemplate NameNote TextAnesthetic, Specific Tooth(Anesthetic, Topical) was placed on the (Anesthetic Area), adjacent to tooth (Anesthetic for Tooth).

2 A total of (Carpules, Qty) (Carpules, Fraction) carpules of (Anesthetic, Local) was injected into the (Anesthetic Area) using a (Anesthetic, Needle Length), (Anesthetic, Needle Gauge)-gauge needle. A suck-back safety syringe was used to avoid inter-vesicular injection. The patient tolerated the (Anesthetic, Local) injection and had no adverse reactions to the Anesthetic, BriefThe patient was given (Carpules, Qty) (Carpules, Fraction) total carpules of (Anesthetic, Local) to achieve satisfactory local anesthesia Injection Given to PatientNo injection was given to the patient. (Anesthetic, None Given) for the dental : CliniCal examsTemplate NameNote TextCosmetic AberrationThe patient has (Cosmetic Aberration), (Cosmetic Aberration Treatable). (Cosmetic Aberration Notes)Cosmetic IssueThe patient has (Cosmetic Level) (Cosmetic Issue) in the (Cosmetic Area) TypeExam Type: (Exam Type)Functional Evaluation, TMJA Functional Evaluation of the patient s TMJ shows the following: Motion/Deviation: (Eval TMJ, Motion/Deviation) Subluxation/Crepitus: (Eval TMJ, Subluxation/Crepitus) Symptoms Reported: (Eval TMJ, Symptoms Report) Diagnosis: (Eval TMJ, Diagnosis)Myofunctional AnalysisA Functional Evaluation, Myofunctional Analysis shows the following.

3 Tongue Habits: (Eval MA, Tongue Habits) Lip Habits: (Eval MA, Lip Habits) Speech: (Eval MA, Speech) 2 Category: CliniCal exams (Continued)Template NameNote TextOcclusionA Functional Evaluation of the patient s Occlusion shows the following. Occlusion Classification: (Occlusion, Classification) Left Lateral: (Occlusion, Left Lateral) Right Lateral: (Occlusion, Right Lateral) Space for Appliances: (Occlusion, Appliance Space) Overall Spacing: (Occlusion, Overall Spacing) Crowding: (Occlusion, Crowding) Crossbite: (Occlusion, Crossbite) Arch Length: (Occlusion, Arch Length) Overbite (mm): (Occlusion, Overbite (mm)) Overjet (mm): (Occlusion, Overjet (mm)) Patient s perceived level of function: (Occlusion, Function, Patient) Dentist s perceived level of function: (Occlusion, Function, Dr.)

4 Patient s perceived level of aesthetics: (Occlusion, Aesthetic, Patient) Dentist s perceived level of aesthetics: (Occlusion, Aesthetic, Dr.)Oral HygieneThe patient s overall Oral Hygiene is (Oral Hygiene, Overall). Today s exam shows the following. Plaque: (Oral Hygiene, Plaque) Calculus: (Oral Hygiene, Calculus) Stain: (Oral Hygiene, Stain) Food Impaction Areas: (Oral Hygiene, Food Impaction) Oral PathologyThe patient has (Oral Pathology Level) (Oral Pathology Type) oral pathology. (Oral Pathology Treatment) is recommended. The prognosis is (Oral Pathology Prognosis). (Oral Pathology, Tooth Related).Patient HabitsAn evaluation of the patient s habits pertaining to their oral health shows the following. Cigar/Cigarette Smoking: (Habits, Cig Smoking) Pipe Smoking: (Habits, Pipe Smoking) Nail Biting: (Habits, Nail Biting) Smokeless Tobacco Use: (Habits, Chewing Tobacco) thumb /Finger sucking : (Habits, thumb sucking ) Toothpick/Stimulator Use: (Habits, Toothpick Use) Gum Chewing: (Habits, Gum Chewing) Teeth Grinding/Clenching: (Habits, Teeth Grind/Clench) Cheek Biting: (Habits, Cheek Biting) Tongue Thrusting: (Habits, Tongue Thrusting) Mouth Breathing: (Habits, Mouth Breathing) Bulemia/Anorexia: (Habits, Bulemia/Anorexia) Substance Abuse: (Habits, Substance Abuse) Other Habits: (Habits, Other)Patient HealthPatient health conditions.

5 (Health Issues)Restorative IssuesThe patient exhibits (Decay Level) existing patient is missing the following teeth: (Tooth-Missing)The patient has the following additional restorative issues: (Restorative Issues)Soft Tissue ExamA Soft Tissue Exam shows the following. Extraoral Head/Neck: (STE Extraoral Head/Neck) Lymph Chain: (STE Lymph Chain) Lips: (STE Lips) Labial/Buccal Mucosa: (STE Labial/Buccal Mucosa) Tongue: (STE Tongue) Floor of Mouth: (STE Floor of Mouth) Palate, Hard/Soft: (STE Palate, Hard/Soft) Pharynx: (STE Pharynx) 3 Category: endodontiCsTemplate NameNote TextAttempted Root Canal, ClosedAttempted root canal treatment on tooth (Tooth-Receiving Treatment).

6 Examination of the X-ray revealed that the canal has closed off. The patient has been informed that the tooth can either be extracted and crowned or have a post and core and be crowned. A treatment plan is being Pulp Test ReadingA pulp test was administered on tooth (Tooth-Select One). The pulpal reading was (Pulp Test). The high test result indicates that the nerve is dead and the tooth is abscessed. The patient has agreed to (Tx Plan).Low Pulp Test ReadingA pulp test was administered on tooth (Tooth-Select One). The pulpal reading was (Pulp Test). The low result represents a normal reading for the : Fixed ProsthetiCsTemplate NameNote TextCrown Replaced Large AmalagamThe amalgam restoration covering the (Surfaces Covered-Old) surface(s) of tooth (Tooth-Receiving Treatment) has been replaced with a to be ReplacedThe (Crown Type) crown on tooth (Tooth-Select One) needs to be replaced due to (Crown Replacement Reason).

7 Pre-Op ImpressionAn impression has been taken using alginate hydrocolloid in order to fabricate a temporary (Tx Plan, Bridge/Crown).Ready for CrownTooth (Tooth-Select One) is in need of a crown. The tooth has already had a (Tx Plan, Ready for Crown).Shade Guide SelectedPatient has selected (Shade Guide) (Shade Letter) (Shade #) as the Shade Guide for use on the (Tx Plan, Bridge/Crown) for tooth (Tooth-Receiving Treatment).Stumpshade SelectedA stumpshade was selected to be used in conjunction with the Shade Guide for the (Tx Plan, Bridge/Crown) on tooth (Tooth-Receiving Treatment). (Shade Guide) (Shade Letter) (Shade #) will be used as the shade on the (Surface-Select Text) surface of the (Tx Plan, Bridge/Crown).Category: hygieneTemplate NameNote TextOral Hygiene InstructionsProper technique of brushing demonstrated.

8 Flossing with fingers and a floss holder demonstrated. Patient given a soft toothbrush and RinsePatient rinsed with (Oral Rinse) after (Prophy Scaling) scaling with hand instruments. Flossed all : mediCal alertsTemplate NameNote TextAntibiotic Pre-Med ConfirmedThe patient confirmed that they pre-medicated with (Rx Drug Name) one hour prior to today s appointment, as instructed. The patient s dental chart indicates that they must be pre-medicated prior to any dental treatment. The patient was instructed to pre-medicate with two grams of the antibiotic (4 pills) one hour prior to today s Pre-Med NegativeThe patient was asked if they pre-medicated with antibiotics one hour prior to today s appointment. The patient s dental chart indicates that they must be pre-medicated prior to any dental treatment.

9 The patient stated that they DID NOT pre-medicate prior to today s appointment. The patient was History UpdatedBefore dental treatment, the patient was asked about changes to their medical history such as a recent surgery or changes in medication. Patient confirmed verbally that there have been changes in their medical history. These changes have been recorded and updated in the patient s : mediCal alerts (Continued)Template NameNote TextHealth History, No ChangeBefore dental treatment, the patient was asked about changes to their medical history such as a recent surgery or changes in medication. Patient confirmed verbally that there have been NO changes in their medical History, NoneThe patient has stated that they are not currently taking any medications, do not have any health issues, and have no need to be under a doctor s care at this : orthodontiCsTemplate NameNote TextOrthodontic ExtractionThe following teeth were extracted for orthodontic purposes: (Tooth-Select Multiple).

10 A letter from the orthodontist instructed that the teeth be ReferralPatient has been given an orthodontic referral to discuss options with, and seek treatment from an orthodontist for correction of (Ortho Issue).Category: Patient ComPlaintTemplate NameNote TextPain, Hard TissueThe patient has pain in the following teeth: (Tooth-Select Multiple)Pain, No SwellingPatient experiences pain but has no swelling in the (Quadrant-With Pain) quadrant. The pain seems to be associated with tooth (Tooth-With Pain).Pain, SwellingPatient complains of pain and swelling in the (Quadrant-With Pain) quadrant. The swelling is located near the (Surface-Select Text) surface of tooth (Tooth-Select One).Pain, Soft TissueThere is evidence of (Pain Manifestation) on the (Pain Area) adjacent to tooth (Tooth-Select One).