DENTAL PROGRESS NOTE

Patient: [Name]
Date of birth: [Date]
Date of visit: [Date]
Dentist: [Name, credentials]
Assistant: [Name]
Tooth numbering: [Universal, or FDI if your practice uses it]

CHIEF CONCERN
Reason for visit: [Planned treatment, or the patient's concern in their words]
Symptoms: [Pain, sensitivity to cold, heat, or biting, swelling, and for how long]

MEDICAL HISTORY UPDATE
Changes: [New conditions, hospital stays, or pregnancy since the last visit, or no changes]
Medications: [Current list, including blood thinners and bone-modifying drugs]
Allergies: [Drug, latex, and other allergies, with reactions]
Premedication: [Antibiotic prophylaxis if indicated, with drug, dose, and time taken; or not indicated]
Vital signs: [BP and pulse, if taken]

CONSENT
Discussed: [Diagnosis, proposed treatment, risks, benefits, and alternatives, including no treatment]
Consent: [Verbal or written; questions answered]

ANESTHESIA
Topical: [Agent and site, or none]
Local anesthetic: [Agent, concentration, and vasoconstrictor]
Amount: [Number of cartridges and total volume in mL]
Technique and site: [Block or infiltration, nerve or tooth, and side]
Aspiration and effect: [Aspiration result, depth of anesthesia, any reaction]

PROCEDURE
Tooth and surfaces: [Tooth number and surfaces, such as #30 MO]
Diagnosis: [Caries, fracture, non-restorable tooth, or other]
Isolation: [Rubber dam, cotton rolls, or isolation system]
Details: [Steps, preparation depth, pulp exposure or not, complications]
Materials: [Liner, adhesive, restorative material and shade, sutures, hemostatic agents]
Occlusion and contacts: [Checked and adjusted; floss through contacts]
Radiographs: [Type, teeth, and findings, or none taken]
Tolerance: [How the patient tolerated the procedure]

POST-OPERATIVE INSTRUCTIONS
Instructions: [Verbal and written; what was covered]
Pain relief: [Medication, dose, and frequency, or none needed]
When to call: [Bleeding, swelling, fever, lingering pain, or a high bite]

NEXT VISIT
Next appointment: [Treatment, teeth, and time frame]
Remaining treatment: [Outstanding items in the treatment plan]

Signed: [Dentist name, credentials, date and time]