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Medical History: Checked, no changes, see attached sheet.
Consent to start treatment: Written/Verbal
Occlusion and lateral guidance checked before preparation.
Local Anaesthetic:
.....
Isolation obtained.
Occlusal reduction carried out until adequate clearance obtained, axial reduction performed.
Good taper, no overhangs.
Impression taken in putty and light body wash in stock tray. Opposing impression in alginate. Bite recorded. / Impression and bite recorded with intra-oral scan.
Temporary crown made with composite.
Shade chosen with patient: …..
Post-operative instructions given regarding local anaesthetic and temporary crown. Patient given an opportunity to ask questions.
Next Visit: Fit appointment
Preparing for a crown or onlay procedure demands meticulous attention to detail, not only in the dental craftsmanship but also in the documentation. Accurate and comprehensive notes are integral to track the procedural steps taken and serve as an essential communication tool between dental professionals. This guide and the included template will help you to create precise, detailed notes for crown or onlay preparations in 2024.
Detailed clinical notes underpin the quality of care by recording patient consent, procedural steps, clinical findings, and treatment outcomes. In addition to ensuring continuity of care, they provide legal documentation of the procedures performed and support any necessary follow-up treatments.
Get started by copying the template above for your next crown/onlay preparation procedure.
By utilizing this crown or onlay preparation notes template, dentists will be able to maintain consistent and comprehensive dental records. This contributes significantly to the quality of patient care, practice efficiency, and accurate communication of treatment between dental team members and laboratories. Implementing such a template is an effective way to modernize and optimize dental practice note-taking in 2024.
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