Dr.+Lee+Example+Treatment+Notes

__** SAMPLE OD NOTES: **__

nv – cont OD
 * 1 st ** **OD**: RMH, VS: (BP, Temp, Pulse, Respirations), no acute dental CC, EO IO exm NSF, FMX taken, facebow and max/mand alginate impressions taken with stock trays for dx casts, started Form 4.

Endo consult with Dr. X: Recommend re-tx of #12; pt informed re-tx will be referred to private care. Formulated preliminary restorative tx plan and reviewed with pt. nv – tx plan presentation nv – Comp Perio Eval (9A), finalize definitive Perio Phase I tx plan (SRPs etc)
 * 2 nd ** **OD**: Pt arrived 15 minutes late due to traffic. RMH – no changes (VS as appropriate), no acute dental CC, continued Form 4, reviewed dental findings, approved preliminary Perio Phase I tx plan.

**Final OD**: RMH – no changes (VS prn), no acute dental CC. Reviewed RBE (risks, benefits, explanations) and tx options w/ pt including but not limited to: • PFM FPD #12-14 • DI#13 • RPD (#13) • Etc Pt opts for PFM FPD #12-14 due to cost and time. Pt signed tx plan and understands this is an estimate and is subject to change. nv – (complete perio stabilization) nv – (priority Phase I caries control)

__** SAMPLE RESTORATIVE NOTES: **__

**#12 MOD R**: RMH – no changes (VS as appropriate), no acute dental CC. LARD (local anesthetic rubber damn) 2% Lido 1:100k epi 1 carp local infiltration, MOD existing amalgam and caries removal, deep, neg car exposure, Vitrebond GI liner, AE Optibond Solo+, A3 Premise, checked occlusion, polished with Enhance tips, POIG, OHIG. Pt informed may need endo prn symptoms; pt told to call if any acute symptoms occur and/or persist. nv - #14 MO/OL R

**#3 BU**: RMH – no changes (VS as appropriate), no acute dental CC. LARD 2% Lido 1:100k epi 1 carp local infiltration, MODBL existing resin/caries removal, deep, neg car exposure, Vitrebond GI liner, AE, A/B Paracore adhesive, White Paracore BU placed, checked occlusion, POIG, OHIG. Pt informed may need endo prn symptoms; pt told to call if any acute symptoms occur and/or persist. nv - #3 FCG

**#3 FCG**: RMH – no changes (VS as appropriate), no acute dental CC. (Current baseline PA and 6-point probing depths recommended when start any Fixed Pros) Stent for provisional prefabricated OR Exabite PVS dual-arch impression taken for provisional. LA 2% Lido 1:100k epi 1 carp local infiltration, FCG prep, packed 0 and 00 cords with Hemodent, full arch Affinis H/L PVS impression taken with custom tray, cords removed, fab A2 Integrity provisional, checked occlusion, cemented with ZONE, verified occlusion, POIG, OHIG. (Mand alg impr taken for opposer.) nv – seat #3 FCG, pre and post-seat films

**Seat #3 FCG**: RMH – no changes (VS as appropriate), no acute dental CC. No LA, prov/temp cement removal, tried in #3 FCG, checked fit/margins, adjusted M and D contacts, checked occlusion, pt happy with fit and esthetics, pre-seat film taken, polished, cemented with Fuji+, verified occlusion, post-seat film taken, POIG, OHIG. nv - #8 APC

**OCCLUSAL RECORDS F/F**: RMH – no changes (VS as appropriate), no dental CC. Tried in wax rims, adjusted bases for overextension and relief of frenae, adjusted wax for proper OVD and desired facial profile, verified with Fox Plane, pt comfortable with fit. Esthetic midline, canine references marked. Posterior palatal seal recorded. Exabite PVS bite registration taken. Shade X and Mould X approved by pt. nv – Esthetic Try-in F/F

**S:** Pt reports intermittent pain UL X 3 days, getting worse **O:** PA/BW taken #14 PA/BW reveal MOD caries; PA reveals + PA involvement Multiple stress fxs; pt reports PM grinding with no hx of splint use. Ibuprofen with little relief per pt; now more spontaneous pain. Endo consult with Dr X: Recommend RCT #14. **A:** #14 symptomatic apical periodontitis, acute irreversible pulpitis secondary to CTS **P:** Reviewed findings with pt including but not limited to recommendation for RCT/BU and full coverage and revd tx estimate. Rxes given for PenVK 500mg and Vicodin. POIG. nv - #14 RCT
 * L ** **E (Emerg)**: RMH – pt taking OTC 600mg ibuprofen prn TA q6-8h, no other changes. VS (important in acute care visit, esp TEMP!)
 * 1) 14 +++ cold test with +lingering response; #12, 13, 15, 18-20 neg
 * 2) 14 +++ perc/palp; #12, 13, 15, 18-20 neg
 * 3) 14 +++ bitestick; #12, 13, 15, 18-20 neg
 * 4) 14 Probing depths: (xxxxxx)
 * 1) 14 + localized marginal inflammation; neg facial swelling; neg fever; pt NAD.