Accurate and detailed patient documentation is crucial for any dental practitioner, especially within the prosthodontics specialty. Well-organized clinical notes not only enhance patient care but also facilitate effective communication among healthcare providers. In this guide, we will explore how to meticulously document a dental examination or consultation using a structured template.

Chief Complaint (CO)

Begin by capturing the patient's primary concern or reason for the visit. This sets the stage for the consultation and helps guide the examination. For instance, "Patient reports sensitivity in the upper right molar region for the past two weeks, exacerbated by cold drinks."

Medical History (MH)

Document the patient’s medical history to identify any conditions that might affect dental treatment. For example, "Fit and healthy with no known drug allergies."

Social History (SH)

Include lifestyle factors that might influence oral health, such as smoking and alcohol consumption, along with occupational details. An example entry could be, "Non-smoker. Drinking 5 units of alcohol per week. Occupation: Software Engineer."

Dental History (DH)

Record the patient's past dental visits and any significant dental history. For example, "Last dental visit was 6 months ago."

Oral Hygiene Regimen

Note the patient's oral hygiene practices to assess their impact on oral health. An example might be, "Brushing 2 x daily with an electric toothbrush, flossing daily with interdental brushes."

Oral Examination (OE)

Detail the findings of both extraoral (E/O) and intraoral (I/O) examinations. For instance:

E/O: TMJ, muscles of mastication, facial symmetry, lips, lymph nodes all OK.

I/O: Soft tissues: Hard/soft palate, buccal mucosa, tongue, floor of mouth, all OK.

Dentition and Periodontal Status

Document the condition of the teeth and periodontium. For example, "Dentition: No caries detected. Slight wear on the upper right molar. Gingivae: Healthy. Calculus: Minimal."

Risk Assessment

Assess and record the patient's risk for caries, periodontitis, and oral cancer. An example entry might be, "Caries risk: Low risk. Periodontitis risk: Low risk. Oral cancer risk: Low risk."

Radiographic Findings (Rads)

Include any radiographic assessments conducted during the examination. For instance, "R+L BWs taken Q1. Assess caries and crestal bone levels: No caries or bone loss detected."

Diagnosis (Dx) and Treatment Plan

Provide a clear diagnosis and discuss treatment options with the patient, noting their decision. For example, "Dx: Mild dental wear on the upper right molar. Discussed Dx with patient. Explained wear is likely due to bruxism and recommended a night guard. Pt opted for: Night guard."

Patient Advice and Recall

Conclude with advice on oral hygiene and dietary habits, and recommend a follow-up schedule. For instance, "Oral hygiene given to pt - advised to brush along gingival margins and interproximally with tepes/floss. Diet adv given and adv to limit sugar to meal times only. Recall: Next dental check-up advised in 6 months."

In prosthodontics, the documentation process can be time-consuming and meticulous. This is where AI medical scribes like Notis AI Medical Scribe come into play, offering significant enhancements in efficiency and accuracy.

Time Efficiency

Notis AI Medical Scribe dramatically reduces the time spent on patient documentation, allowing prosthodontists to devote more attention to patient care. By automating the transcription of clinical notes, Notis helps save up to two hours daily on administrative tasks.

Seamless Integration and Ease of Use

Operating directly through WhatsApp, Notis eliminates the need for additional software, providing a user-friendly interface familiar to most practitioners. This seamless integration ensures a smooth transition into using AI for documentation.

High Accuracy and Structured Documentation

Leveraging advanced voice-to-text technology, Notis offers 99% accuracy in transcribing medical notes, converting patient consultations into structured SOAP notes instantly. This ensures comprehensive and precise documentation critical for prosthodontic care.

In conclusion, utilizing AI medical scribes like Notis in prosthodontics not only optimizes the documentation process but also enhances patient care by allowing practitioners to focus more on clinical duties rather than administrative tasks. Embracing such technology is a step forward in modernizing healthcare practices and improving overall efficiency.