Creating precise and detailed new patient notes is critical for periodontists. The documentation must be clear, comprehensive, and follow a structured template to ensure all essential information is captured. Below is a step-by-step guide on writing new patient notes using the provided template.

Begin with the details of the referring doctor and treatment coordinator. This information is crucial for coordinating care and ensuring seamless communication between all parties involved. For example:

Referring Doctor: Dr. Emily Johnson

Treatment Coordinator: Sarah Lee

The chief complaint section succinctly describes the primary issue the patient is experiencing, as reported by the patient. It sets the stage for further exploration in the history section. Example:

Chief Complaint: Swollen and bleeding gums for the past 3 weeks

Here, detail the patient's description of their symptoms, including onset, duration, and factors affecting the symptoms. This narrative provides context for the chief complaint. Example:

The patient reports swollen and bleeding gums that started 3 weeks ago. The symptoms have progressively worsened, especially after brushing. The patient experiences mild pain and discomfort, which is alleviated by using a soft-bristled toothbrush. No cosmetic concerns were mentioned.

Document any relevant dental and medical history, including past treatments and current medications. This section helps identify underlying factors that may influence the current condition. Example:

Past Dental History: The patient had a root canal treatment on the upper right molar in 2019, which was successful. No significant dental diseases or injuries reported.

Past Medical History: The patient has a history of hypertension, managed with medication. No known allergies. Currently taking Lisinopril.

Personal habits and family history can provide insights into the patient's condition and potential genetic factors. Example:

Personal History: The patient brushes twice daily but does not floss regularly. No habits of clenching, grinding, or tobacco use. Occasional alcohol intake reported.

Family History: The patient's mother had a history of periodontal disease.

Both extra oral and intra oral examinations should be thoroughly documented to capture the clinical observations. This section is crucial for forming a diagnosis. Example:

Extra Oral Examination: No lymph node enlargement. Facial symmetry is normal. TMJ examination shows normal range of motion.

Intra Oral Examination: Soft tissue examination reveals inflamed and swollen gingiva, particularly in the anterior region. Gingival examination shows redness, bleeding on probing, and moderate plaque accumulation. Hard tissue examination indicates no caries or missing teeth. Oral hygiene status is fair based on the OHI index. Occlusion analysis shows normal occlusion with no significant findings.

Include any radiographic and laboratory findings that support the diagnosis. These data are essential for confirming clinical suspicions. Example:

Radiographic Findings: Panoramic radiograph shows mild bone loss around the molars. No caries or cysts detected.

Laboratory Investigations: Blood sugar levels are within normal range. No other investigations conducted.

Based on the gathered information, provide the diagnosis and prognosis. This section guides the treatment plan. Example:

Diagnoses: Generalized gingivitis with localized periodontitis.

Prognosis: Good overall prognosis with appropriate treatment. Teeth at risk include the lower molars due to localized periodontitis.

Outline the recommended treatment plan and discuss any financial considerations with the patient. This ensures transparency and sets expectations. Example:

Treatment: Scaling and root planing recommended. Oral hygiene instructions provided, including the use of interdental brushes. Follow-up appointment scheduled in 4 weeks.

Financial Notes: Discussed treatment costs and insurance coverage with the patient.

In the fast-paced world of periodontics, efficiency is key. This is where AI medical scribes like Notis AI Medical Scribe come into play. Notis is designed to streamline the documentation process, allowing periodontists to focus more on patient care rather than administrative tasks.

Notis significantly reduces documentation time, cutting it by up to 80%. This means clinicians can save up to 2 hours a day, reducing burnout and increasing productivity. The ease of integration with platforms like WhatsApp ensures that users can transition smoothly without needing to learn new tools.

With an impressive 99% accuracy in voice-to-text transcription, Notis ensures that clinical notes are precise and reliable. The AI system automatically structures these notes into SOAP format, enhancing the quality and consistency of medical documentation.

Notis offers features like natural language search and document analysis, making it a powerful tool for patient documentation and charting. The ability to customize and receive support through its Pro plan adds further value to its service, making it an indispensable asset for any periodontist seeking to optimize their practice.

In conclusion, mastering new patient notes is essential for effective patient management in periodontics. By leveraging advanced tools like Notis AI Medical Scribe, periodontists can enhance their documentation processes, ensuring accuracy and efficiency while dedicating more time to providing quality patient care.