Fillable Default CliniCal note templates

Fill Online, Printable, Fillable, Blank Default CliniCal note templates Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Default CliniCal note templates

On average this form takes 2 minutes to complete

The Default CliniCal note templates form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 8 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Default CliniCal note templates
e 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. e 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
italicized.
Category: administrative
Template Name Note Text
Cancelled Appt <24-Hr Notice The patient cancelled their appointment with less than 24-hour notice.
Patient Dismissed The 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
dentist.
Patient Failed Confirmed Appt The patient’s appointment was previously confirmed, and the patient did not arrive at the office
for their scheduled appointment.
Return Appointment The patient (Return Appointment) to finish treatment.
Category: anesthetiCs
Template Name Note Text
Anesthetic, Specific Tooth (Anesthetic, Topical) was placed on the (Anesthetic Area), adjacent to tooth (Anesthetic for
Tooth). 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.
Local Anesthetic, Brief The patient was given (Carpules, Qty) (Carpules, Fraction) total carpules of (Anesthetic, Local)
to achieve satisfactory local anesthesia results.
No Injection Given to Patient No injection was given to the patient. (Anesthetic, None Given) for the dental treatment.
Category: CliniCal exams
Template Name Note Text
Cosmetic Aberration The patient has (Cosmetic Aberration), (Cosmetic Aberration Treatable). (Cosmetic Aberration
Notes)
Cosmetic Issue The patient has (Cosmetic Level) (Cosmetic Issue) in the (Cosmetic Area) area.
Exam Type Exam Type: (Exam Type)
Functional Evaluation, TMJ A 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 Analysis A Functional Evaluation, Myofunctional Analysis shows the following.
Tongue Habits: (Eval MA, Tongue Habits)
Lip Habits: (Eval MA, Lip Habits)
Speech: (Eval MA, Speech)
2
Category: CliniCal exams (Continued)
Template Name Note Text
Occlusion A 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.)
Patient’s perceived level of aesthetics: (Occlusion, Aesthetic, Patient)
Dentist’s perceived level of aesthetics: (Occlusion, Aesthetic, Dr.)
Oral Hygiene The 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 Pathology The 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 Habits An 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 Health Patient health conditions: (Health Issues)
Restorative Issues The patient exhibits (Decay Level) existing decay.
The patient is missing the following teeth: (Tooth-Missing)
The patient has the following additional restorative issues: (Restorative Issues)
Soft Tissue Exam A 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: endodontiCs
Template Name Note Text
Attempted Root Canal, Closed Attempted root canal treatment on tooth (Tooth-Receiving Treatment). 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 determined.
High Pulp Test Reading A 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 Reading A pulp test was administered on tooth (Tooth-Select One). The pulpal reading was (Pulp Test).
The low result represents a normal reading for the tooth.
Category: Fixed ProsthetiCs
Template Name Note Text
Crown Replaced Large
Amalagam
The amalgam restoration covering the (Surfaces Covered-Old) surface(s) of tooth (Tooth-
Receiving Treatment) has been replaced with a crown.
Crown to be Replaced The (Crown Type) crown on tooth (Tooth-Select One) needs to be replaced due to (Crown
Replacement Reason).
Pre-Op Impression An impression has been taken using alginate hydrocolloid in order to fabricate a temporary (Tx
Plan, Bridge/Crown).
Ready for Crown Tooth (Tooth-Select One) is in need of a crown. The tooth has already had a (Tx Plan, Ready for
Crown).
Shade Guide Selected Patient 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 Selected A 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: hygiene
Template Name Note Text
Oral Hygiene Instructions Proper technique of brushing demonstrated. Flossing with fingers and a floss holder
demonstrated. Patient given a soft toothbrush and floss.
Oral Rinse Patient rinsed with (Oral Rinse) after treatment.
Prophylaxis Performed (Prophy Scaling) scaling with hand instruments. Flossed all contacts.
Category: mediCal alerts
Template Name Note Text
Antibiotic Pre-Med Confirmed The 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 appointment.
Antibiotic Pre-Med Negative The 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. The patient stated that they DID NOT pre-medicate prior to today’s
appointment. The patient was re-appointed.
Health History Updated Before 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 chart.
4
Category: mediCal alerts (Continued)
Template Name Note Text
Health History, No Change Before 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.
Health History, None The 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 time.
Category: orthodontiCs
Template Name Note Text
Orthodontic Extraction The following teeth were extracted for orthodontic purposes: (Tooth-Select Multiple). A letter
from the orthodontist instructed that the teeth be extracted.
Orthodontic Referral Patient has been given an orthodontic referral to discuss options with, and seek treatment from
an orthodontist for correction of (Ortho Issue).
Category: Patient ComPlaint
Template Name Note Text
Pain, Hard Tissue The patient has pain in the following teeth: (Tooth-Select Multiple)
Pain, No Swelling Patient experiences pain but has no swelling in the (Quadrant-With Pain) quadrant. The pain
seems to be associated with tooth (Tooth-With Pain).
Pain, Swelling Patient 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 Tissue There is evidence of (Pain Manifestation) on the (Pain Area) adjacent to tooth (Tooth-Select
One). From the patient’s description it is determined that the pain level is (Pain Level).
TMJ Joint Problem Patient complained of pain in the following joint(s): (TMJ Joints).
Ulcers in Mouth The patient complained of pain in the oral cavity. An examination revealed the presence of an
ulcerated, white, circular lesion of (Size of Ulcer) in diameter, on the mucosa in the (Quadrant-
With Pain) quadrant, on the (Surface-Select Text) surface adjacent to tooth (Tooth-Select One).
Category: PedodontiCs
Template Name Note Text
Topical Anesthesia, Extraction Topical anesthetic was used to numb the gum tissue surrounding tooth (Tooth-Select One) prior
to the extraction of the tooth.
Severe Pulpal Exposure Examination revealed that tooth (Tooth-Select One) had a severe pulpal exposure. Options
were discussed, and the patient’s family chose to have the tooth extracted.
Category: PeriodontiCs
Template Name Note Text
Deep Root Scaling, Quadrant(s) Deep root scaling was used to remove deep calculus from the teeth in the (Quadrant-Select
Multiple) quadrant(s) of the mouth. Patient rinsed with (Oral Rinse) after treatment.
Deep Root Scaling, Teeth Deep root scaling was used to remove deep calculus from the following teeth: (Tooth-Select
Multiple). Patient rinsed with (Oral Rinse) after treatment.
5
Category: PeriodontiCs (Continued)
Template Name Note Text
Periodontal Exam Notes A periodontal exam indicates the following for quadrant(s): (Quadrant-Select Multiple).
Classification: (Perio, Classification)
Gingiva Color: (Perio, Color)
Gingival Inflammation: (Perio, Inflammation)
Free Gingival Margins: (Perio, Margins)
Interdental Papillae: (Perio, Papillae)
Gingiva Consistency: (Perio, Consistency)
Gingiva Surface Texture: (Perio, Texture)
Attached Gingiva: (Perio, Attached Gingiva)
Gingival Sulcus: (Perio, Sulcus)
Gingival Bleeding: (Perio, Bleeding)
Suppuration: (Perio, Suppuration)
Pattern of Bone Loss: (Perio, Bone Loss Pattern)
Severity of Bone Loss: (Perio, Bone Loss Severity)
Plaque: (Perio, Plaque)
Calculus: (Perio, Calculus)
Dentinal Hypersensitivity: (Perio, Hypersensitivity)
Tooth Stain: (Perio, Stain)
Tooth Stain Pigment: (Perio, Stain Pigment)
Other: (Perio, Miscellaneous)
Referral to Periodontist Patient has been referred to a periodontist for further treatment.
Category: PresCriPtions
Template Name Note Text
No Medication or Antibiotic Neither pain medication nor antibiotics were given to the patient. The patient understood that
their procedure was minor and did not require the use of either pain medication or antibiotics.
Prescription The patient has been given the following prescription:
(Rx Drug Name), (Rx Quantity); (Rx Sig - Instructions). There are (Rx Refills) refills on the
prescription. Prescription instructions have been given to the patient and the patient has
confirmed that they understand the instructions.
Prescription to Pharmacy The patient’s prescription was (Rx to Pharmacy).
Category: reCommendations
Template Name Note Text
Patient Referred The patient has been referred to (Patient Referred, Specialty) for (Patient Referred, Reason).
Patient, Consider Tx Options The patient has been presented with several treatment options and understands that they need
to schedule an appointment and return to the office for treatment when they have decided
upon a treatment plan.
Treatment Importance The importance of making and keeping treatment appointments has been discussed. A
printout of costs associated with treatment has been given to the patient. The patient
understands that if they do not seek immediate dental treatment the costs of restoring their
dentition could increase significantly and may or may not include additional procedures such as
root canals and crowns.
Category: removable ProsthetiCs
Template Name Note Text
Add Multiple Teeth, Removable Additional teeth have been added to the patient’s removable appliance: (Tooth-Select
Multiple).
6
Category: removable ProsthetiCs (Continued)
Template Name Note Text
Occlusal Bite Guard Delivered An Occlusal Bite Guard was delivered to the patient. The patient has been instructed to wear
the bite guard at night. The patient has also been encouraged to wear the guard any time they
are biting or grinding their teeth.
Patient Instructions The patient has been given their removable appliance and has been instructed to return to the
office if they experience any discomfort related to the appliance or if the appliance requires any
adjustments.
Category: restorative
Template Name Note Text
Chip in Tooth, Large The (Surface-Select Text) surface of tooth (Tooth-Select One) has been chipped. The patient
has been advised that since the chip is large the tooth will need (Tx Plan). Patient will make an
appointment for treatment.
Chip in Tooth, Small The (Surface-Select Text) surface of tooth (Tooth-Select One) has been chipped. The patient
has been advised that since the chip is relatively small the best treatment option is sanding,
smoothing and polishing.
Crown Cemented The (Crown Type) crown on tooth (Tooth-Receiving Treatment) was cemented using (Cement,
Permanent), phosphoric acid etchant (Phosphoric Acid Etchant %), and (Bonding Agent). One
digital X-ray was taken to verify fit and ensure removal of excess cement. The patient received
(Post-Op Instructions) post-op instructions.
Crown Off, Structure Sound The crown came off tooth (Tooth-Select One). Examination revealed both the tooth and the
crown to be in good structural condition. Crown cleaned and re-cemented to tooth using
(Cement, Permanent). Patient advised that should this happen again the crown will need to be
replaced.
Crown Off, Structure Unsound The crown came off tooth (Tooth-Select One). Examination revealed part of the tooth structure
to have broken off with the crown. Patient has been advised that re-cementing the crown is not
an option because of the broken tooth. Several treatment options were presented, including a
root canal with a post and core and a new crown. Patient has agreed to (Tx Plan) to repair the
tooth.
Fractured Crown The (Surface-Select Text) surface of the crown on tooth (Tooth-Select One) is fractured. Patient
has agreed to (Tx Plan) to repair the tooth.
Category: treatment
Template Name Note Text
Crown Restoration Post-Op Patient has been given all instructions and information concerning the (Crown Type) crown
placed today. They have been advised regarding the duration of numbness, expected
sensitivity, and amount of time until they can chew. The patient has also been advised to
contact the office if they experience swelling of the jaw or severe pain related to temperature
changes in the mouth.
Post-Op Instructions For today’s treatment, (Post-Op Instructions) post-op instructions were given to the (Post-Op Given).
Category: x-rays
Template Name Note Text
Pat. Confirms Pregnancy, X-ray The patient responded affirmatively when asked whether she was pregnant. X-rays will not be
taken because of her condition.
Used FMX Instead of X-ray No X-ray was taken of the patient. The most recent FMX was used instead.
X-ray, Patient NO Permission A thorough explanation of the benefits and risks associated with the taking of digital x-rays was
verbally discussed with the patient, including the necessity of taking an x-ray on tooth (Tooth-
Select One). Despite my recommendations to have x-rays taken, the patient refused to give
permission to take x-rays and the patient understands the possible consequences of this action.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Default CliniCal note templates

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document