HomeClinic Note Gen Note Type Consult Note Procedure Note Follow Up Note Prescriptions Consult Note Extraction Wisdom Teeth Implant TMJ Pain Scale 0/10 no pain 1/10 mild pain 2/10 mild pain 3/10 moderate pain 4/10 moderate pain 5/10 severe pain 6/10 severe pain 7/10 severe pain 8/10 very severe pain 9/10 very severe pain 10/10 worst pain Age Sex Male Female Exam Type Wisdom teeth Decayed maxillary teeth Decayed mandibular teeth Decayed maxillary/mandibular teeth Maxillary lesion Mandibular lesion Dental implant rehabilitation Other *Other: ** leave PMH, medications and allergies blank and it will output ‘As reviewed and documented in pts chart’ PMH Medications Allergies HPI Neuro Exam Extra-Oral Exam Intra-Oral Exam Radiograpahic Exam Additional Notes Sedation Plan Local Anesthesia Nitrous IV Sedation Mallampati I II III IV TM Distance <3 FB >3 FB Neck ROM Full Limited Mouth Opening <3 FB >3 FB ASA I II III IV V VI Plan Follow-Up Note Extraction F/U Implant F/U Implant Final Check Ortho Sx F/U Reason for F/U Pain Scale 0/10 no pain 1/10 mild pain 2/10 mild pain 3/10 moderate pain 4/10 moderate pain 5/10 severe pain 6/10 severe pain 7/10 severe pain 8/10 very severe pain 9/10 very severe pain 10/10 worst pain Post Op Course Neuro Exam Extra Oral Exam Intra Oral Exam Procedure Sutures Removed Left in Place Dissolved Additional Notes Next Visit Procedures Extraction Wisdom Teeth Implants Uncovering Sinus Lift Alveoloplasty Biopsy Bone Graft Tori Apico Incision & Drainage Expose & Bond CRIMF Sinus Closure Sialolithotomy Implant debride Sedation Nitrous Sedation IV Sedation Macro Extraction Wisdom Teeth Sedation Procedure Note Procedure Pain Scale 0/10 no pain 1/10 mild pain 2/10 mild pain 3/10 moderate pain 4/10 moderate pain 5/10 severe pain 6/10 severe pain 7/10 severe pain 8/10 very severe pain 9/10 very severe pain 10/10 worst pain Risks Mand Ext Max Ext Referral Yes No Time Out Witness Angiocath Size 18g 20g 22g 24g Angiocath Lat. Left Right Angiocath Loc. Hand Forearm ACF Wrist Blood PRP 15cc 30cc 60cc 90cc 120cc Decadron Dose 4mg 8mg 12mg 16mg 20mg Abx Dose 600mg of Clindamycin 2g of Ampicillin 3g of Unasyn 1g of Cefazolin 1g of Ceftriaxone 500mg of Zithromax Xylocaine 34mg 68mg 102mg 136mg 170mg 204mg Septocaine 34mg 68mg 136mg 202mg 270mg Marcaine 9mg 17mg 26mg 34mg Carbocaine 51mg 102mg 153mg 204mg Simple Extractions Simple Extraction Surgical Extractions Surgical Extraction Options FTF Handpiece Alveoloplasty URQ ULQ LRQ LLQ Maxillary Wisdom Teeth Extractions Tooth #1 Erupted Soft Tissue Partial Bone Complete Bone Tooth #16 Erupted Soft Tissue Partial Bone Complete Bone Max WT Distal Release Vertical Release FTF Tuberosity Palatal Tear Mandibular Wisdom Teeth Extractions Tooth #17 Erupted Soft Tissue Partial Bone Complete Bone Tooth #32 Erupted Soft Tissue Partial Bone Complete Bone Mand WT Distal Release FTF Handpiece Coronectomy Vertical Sinus Lift Implant Site #s Schneid. Membrane Intact Perforated Membrane used Chorion/Amnion Surgicel Biomend Xtend Lateral Window Sinus Lift Laterality Left Right Bilateral Schneid. Membrane Intact Perforated Membrane used Chorion/Amnion Surgicel Biomend Xtend Immediate Implants Implant #s Buccal Plate Intact Not Intact Screw Healing Abutment Cover Screw White Caps Multiunit Abutment Membrane Biomend Xtend Straumann Jason Collagen Plug Standard Implants Implant #s Screw Healing Abutment Cover Screw White Caps Multiunit Abutment Implant Log Implant Alveoloplasty Quadrants URQ ULQ LRQ LLQ Hard Tissue Biopsy Site Incision Biopsy Type Incisional Excisional Soft Tissue Biopsy Site Biopsy Type Incisional Excisional Closure Primary Closure Secondary Healing Uncovering Implant #s Implant Type Straumann BLX Straumann BLT NobelReplace Conical Connection NobelReplace Select Tapered Keystone TiLobeMaxx Ridge Graft Recipient Site Bone Graft Cancellous Cortical BioOss Bone Graft X Small Small Medium Large Chin Graft Recipient Site Recipient Site Incision Block Size Screw Stryker Straumann Osteomed Ramal Graft: Recipient Site Recipient Site Incision Block Size Screw Stryker Straumann Osteomed Palatal Torus Incision Double Y Mid-Palatal Incision Intrasulcular/Crestal Incision Splint Yes No Mandibular Torus Incision Area Lateral Exostosis Incision Area Apico Tooth # Incision Type Intrasulcular Semilunar Incision Area Root Buccal Palatal Distal Buccal & Palatal Mesio-Buccal Disto-Buccal Mesio-Lingual Retrograde Fill Amalgam Super EBA IRM Incision & Drainage Tooth # Incision Type Sulcus Vestibule Palate Drainage Type Purulent Serosanguinous Serous Penrose Yes No Expose & Bond Tooth # Localization Palatally Facial/Buccal Incision CRIMF Arch Bar (Max) Arch Bar (Mand) Closed Reduction TMJ Laterality Left Right Both Sinus Closure Tooth # Perforation Root Entire Socket Mesio-Buccal Disto-Buccal Mesio-Lingual Buccal & Palatal Buccal Palatal Distal Incision Fat Pad Yes No Sialolithotomy Gland Lac Probe 4-0 3-0 2-0 1-0 Incision Implant Debride Implant # Status Salvageable Non-Salvageable Bone Graft 50/50 HA/CortCanc Stryker Cort/Canc Allograft Bio-OSS with PRP Stryker with PRP Post-Op Imaging PA Panorex CBCT Midazolam Dose Fentanyl Dose Propofol Dose Ketamine Dose Precedex Dose Sedation Type Minimal Sedation Moderate Sedation Deep Sedation General Anesthesia Toradol Dose Zofran Dose Additional Notes Follow-Up Prescriptions Pain Rx OTC Analgesics Motrin 400mg Motrin 600mg Motrin 800mg Tylenol 500mg Tylenol 1,000mg Tylenol #3 Vicoden Norco Percocet Oxycodone Tramadol Antibiotic Rx Amoxicillin Augmentin Clindamycin Cephalexin Azithromycin Bactrim Doxycycline Moxyfloxacin Decongestant Rx Sudafed Afrin Mucinex Misc Rx Peridex Zofran Medrol Dose Pack Flexeril Robaxin Pentoxifylline Tocopherol Output Note Copy Note Copy Note
