Dr.+Closmann+Example+Note

Med Hx reviewed. No contraindications to surgery noted at this time. Time out performed. The patient was referred by ?? for removal of tooth/teeth ?? because of ?? (give diagnosis, non-restorable tooth, etc). Consent was obtained including most common risks and complications. Local anesthesia was obtained via block and infiltration techniques. A total of ?? carpules of 2% lidocaine with epi 1:100k, and ?? carpules of 4% Septocaine with epi 1:100k were used (you can specify where you gave the anesthetic, but this is not necessary). Tooth/teeth ?? was/were extracted with forceps and elevator technique. The area was irrigated NS. Gauze packs were placed. Good hemostasis was obtained in all fields. Postop instructions were given to patient as well as extra gauze sponges. Patient was prescribed ?? (quantity) of ?? (drug name) for ?? (pain, infection, etc). Patient was instructed to take ?? tablet(s) ?? (bid, tid, qid, qd, every 8 hours, etc). Pt tolerated procedure well. F/u OS prn. F/u with primary dental provider as directed.
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NS = Normal Saline

Things he likes to see:
 * 1) That the med history was reviewed
 * 2) Consent was obtained
 * 3) The type, amount (Carps and or mgs), where it was placed
 * 4) Procedure performed and with what instrument.s
 * 5) Irrigation, with which irrigant (Normal Saline, NS)
 * 6) Good Hemostasis was obtained before they left
 * 7) Perscription - Type, amount, how frequently, etc.
 * 8) Patient tolerated the procedure well.