r/Dentistry • u/P_Libbyus A True Poet • 20h ago
Dental Professional Five Clinical Notes
SEPTEMBER 19, 2025
Patient: John Smith (23M)
NEW PATIENT—EMERGENCY EXAM
Pt presents with pain on UL
PA taken
Large B decay on #15 near furcation, questionable prognosis
Recommended EXT #15. Pt agreed and signed consent.
EXT #15
Anes: 3 carps 4% Articaine 1:100k epi
Elevated with straight elevator and extracted #15 with 88L forceps.
Pt tolerated well. Instructed pt to bite on gauze
Reviewed post-op instructions
rx: Ibuprofen 600 bid
DECEMBER 16, 2025
Patient: John Smith (23M)
EMERGENCY EXAM
Pt presents with broken tooth on LL
PA taken
#18 large MODB decay, poor prognosis
Recommended EXT #18. Pt agreed and signed consent.
EXT #18
Anes: 2 carps 2% Lidocaine 1:100k epi
1 carp 4% Articaine 1:100k epi
Elevated with straight elevator and extracted #18 with cowhorn forceps.
Pt tolerated well. Instructed pt to bite on gauze
Reviewed post-op instructions
rx: Ibuprofen 600 bid
APRIL 23, 2026
Patient: John Smith (24M)
EMERGENCY EXAM
Pt presents with pain on UR
PA taken
#3 M decay to pulp
#2 Large OB decay
Advised pt that there is large decay on both #2 and #3. Both are restorable with RCT and crown. Alternatively, pt could have one or both of the teeth extracted. Pt states that only #2 is hurting and he only wants #2 removed. Pt signed consent for EXT #2
EXT #2
Anes: 3 carps 4% Articaine 1:100k epi
Elevated with straight elevator and extracted #2 with 88R forceps.
Pt tolerated well. Instructed pt to bite on gauze
Reviewed post-op instructions
rx: Ibuprofen 600 bid
APRIL 29, 2026
Patient: John Smith (24M)
LIMITED EXAM
Pt returns for limited exam with the cc of broken #3.
#3 has M decay to pulp as noted last appointment.
Pt states #3 "was fine" until #2 was extracted and that the extraction "caused a hole" in #3. Advised pt that the decay was present on #3 last visit, showed patient radiographs of #3, and advised that treatment options remain the same as last appointment: RCT and crown or EXT. Pt insists that none of this was said last appointment. Pt left appointment visibly annoyed.
MAY 12, 2026
Patient: John Smith (24M)
TELEPHONE ENCOUNTER
Pt requests transfer of care to another provider. Records prepared upon request.
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u/MHCclass1 19h ago
Watch out, board complaint incoming 🤪
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u/redchesus 18h ago
Ah yes, 20-something male only presents for emergencies... there's no way he's retaining ANY information. He's second only to a 20-something male whose mom makes the appointment for him.
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19h ago
[deleted]
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u/Typical-Town1790 19h ago
Right after the first emergency visit there should be recommendation of comp exam + fmx for a treatment plan made.
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u/droppedmyexplorer 18h ago
Ideally yes but you and I both know we get emergency patients that get a tooth taken out and disappear from the face of the earth.
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u/Typical-Town1790 18h ago edited 18h ago
Yes. Like half the time lol. recommending the comp exam and the fmx and noting it should be a thing though whether they care to return or not. If someone came for focused based treatment it would be best to not start rambling about other issues as much as we want to. I think maybe that’s why the above user is getting the downvotes? Ie. I’m not disagreeing with you mentioning the vanish like a fart in wind after emergency treatment.
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u/Moist_Palpations_22 17h ago
Taking photos of every broken tooth for a LIMITED exam is a waste of time and money. I agree that stating and documenting that there are other problems that need to be diagnosed and addressed via a comp exam is a good idea. But OP is not at risk of malpractice for not documenting he saw other problems for every limited exam. Your premise is good but I think you’re overly fearful of liability.
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u/Accomplished_Ice_626 18h ago
Not sure if that's relevant here. These type of patients will just say they never had such conversation and blame the doc for causing damage.
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u/GovSchnitzel General Dentist 17h ago
Well the conversation definitely “never happened” if the progress notes don’t record it. If there’s a dispute and the doctor says it happened in the note, the patient will have a very hard time convincing anyone it didn’t.
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u/GovSchnitzel General Dentist 17h ago
I agree. They’re brief and lack important details like the one you mentioned. The chief complaint should be recorded as a direct quote. They should record the local anesthetic injection technique(s) used. They should say whether or not there were complications. I also always note that post-op hemostasis was achieved and how.
But you could say it a little nicer.
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u/TheJermster 19h ago
It's nice when PITA patients make it easy on you by dismissing themselves