Copy this template, or use Denota to fill it out for you.
Medical History: checked, no changes
Consent: Written / Verbal
Benefits of extraction: Remove pain, reduce risk of spreading infection
Discussed relevant risks: Tooth fracture, surgical extraction (lift gingivae +/- bone removal), damage to adjacent teeth, post-op pain, swelling, bruising, oozing, dry socket, damage to ID nerve/oral antral communication
EXTRACTION:
Local Anaesthetic:
.....
PDL widened with luxator.
Elevation with couplands.
Tooth removed with forceps.
Haemostasis achieved.
Post-Op Instructions:
Leaflet and gauze given
Post op analgesics advised
Advised on post-op pain, bleeding, swelling, bruising, dry socket, and instructions given for the next 4-5 days regarding smoking, looking after socket
Pt given an opp to ask Qs. Pt happy.
Dental extractions are critical procedures that require meticulous documentation for clinical and legal reasons. Providing a structured template promotes consistent, clear, and concise notes, serving as an essential reference for any dental practice. This complete guide includes a template to be used in dental extraction cases in 2024, ensuring that all pertinent information is captured during and after the procedure.
Proper record-keeping for dental extractions gives insights into the patient’s treatment history and decisions, outlines the specifics of the procedure, and documents patient consent and understanding of all relevant information. These notes are vital for post-procedure follow-up, legal protection, and communication with other healthcare providers.
The template above is designed for ease of use during the workflow of a dental extraction. Copy with the button above and paste/edit in your practice's dental software of choice.
Using the provided template ensures that dental professionals gather all necessary information during a dental extraction procedure. It also aids in delivering comprehensive post-operative care advice to the patient. In 2024, such thorough documentation remains the benchmark for patient care and the ethical practice of dentistry.
Watch the demo to see a real example procedure and the notes produced. 📽️
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