Copy this template, or use Denota to fill it out for you.
Patient attended with: …..
Consent gained from child and parent: …..
Safeguarding concerns: None. Good relationship between child and parent
Complaints: ……
Medical History: Checked, no changes, see attached sheet.
Diet: ….
Oral Hygiene: …..
Extra-Oral: TMJ, Lymph nodes, Lips, facial symmetry: NAD
Intra-Oral: Buccal mucosa, palate, gingivae, tongue, floor of mouth: NAD
Oral Hygiene: …..
Cooperation today: ……
Modified BPE: see tab
Current Dentition Stage: Primary / Permanent / Mixed
General Dental Alignment: ……
Orthodontics Referral Needed: ……
RADIOGRAPHS:
Op: ….. Type: Right BW
Reason: To assess bone levels, caries. Grade: A
Findings: …..
RADIOGRAPHS:
Op: …… Type: Left BW
Reason: To assess bone levels, caries. Grade: A
Findings: …….
RADIOGRAPHS:
Op: …… Local Rules followed: Yes Type:
Reason: To assess bone levels, caries, periapical pathology, root morphology, surrounding anatomy
Grade: A
Findings: ……
CARIES RISK STATUS: …..
DIAGNOSIS:
1.
2.
TREATMENT PLAN:
1. Preventive: Oral Hygiene Instruction, Diet advice
2.
DISCUSSION:
Advised to brush 2x daily for 2 mins. Demonstrated brushing technique to brush along gingivae.
Advised to reduce frequency of fermentable carb intake.
Dental development discussed with parent and patient.
Patient and parent given an opportunity to ask questions.
Treatment Carried Out Today:
....
Recall every …… months.
Child dental examinations are paramount in establishing a foundation for lifetime oral health. Thorough documentation is imperative to track developmental changes, identify and address potential issues early, and communicate with parents or guardians. This guide outlines how to capture all facets of a child's dental check-up in 2024 using an effective notes template.
A child's dental exam notes should include the following components: the reason for visit, consent, medical and dental history, diet, oral hygiene habits, examination findings, radiographic assessment, risk status, diagnosis, and treatment plan. These notes form a vital part of the child's health record and assist in anticipating developmental concerns.
Utilize the template above to ensure thorough and standardized documentation during a child's dental examination:
Implementing a comprehensive template for child dental examination notes as outlined above ensures clear and complete documentation. Such practices are essential in providing high-quality pediatric dental care, enabling early detection of oral health issues and facilitating effective communication with both the child and their caregiver in 2024 and beyond.
Watch the demo to see a real example procedure and the notes produced. 📽️
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