What should a dental clinical note include?

Who was seen, what changed in the history, what you found, the diagnosis, the options, what you did, and what happens next. If it is not written down, it is hard to show later that it was said.

Is a template the same as the note?

No. The template is the headings. The note is what happened at that visit. A scribe can fill the headings from the appointment so you are not typing them afterwards.

Dental clinical notes template

A clinical note is the record of one visit. This template is the order I use so nothing that matters is left in my head.

Template

Date and clinician
Attending and medical history changes
Complaint, in the patient's words
Exam findings
Diagnosis
Options discussed, and what the patient chose
Treatment given today
Consent, and any risks named
Next visit, and what the patient was told to watch for

A filled-in example

            12 March 2026, Dr A. Gupta
MH: no change. NKDA.
Complaint: "The filling on the lower left broke yesterday. It is sharp, not painful."
Exam: LL6 large failing composite, caries at the distal margin. LL6 mildly tender to percussion. No swelling.
Diagnosis: secondary caries LL6, pulp likely vital.
Options: replace the filling, or extract if it fails. Patient chose a replacement filling today.
Treatment: LA, caries removed, composite LL6.
Consent: discussed sensitivity and the chance it needs root treatment later.
Next: review if it stays tender. OHI given.

Let Dentascribe fill this in from your appointment audio.

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Common questions