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Templates, Clinical notes, Dental

Dental initial consultation note template

A dental initial consultation note template that sets out what belongs in each section, ready to adapt to your own clinic. Below it is the same note filled in by the wai scribe from an invented consultation, line by line, for the clinician to read and sign.

Updated . Written by our clinical team, generic by design, with no dosing advice.

01Initial consultation note

TemplateDental

Patient
[Name]
Date of birth
[Date]
Record number
[Number]
Clinician
[Name, registration number]
Consultation
[Date and time], [in person or video]

Dental initial consultation note

1Presenting complaint

  • The reason for the visit, in the patient's own words where they are useful.
  • How long it has been going on.

2History of the presenting complaint

  • Site, duration and character of any pain, and what triggers it.
  • Last dental visit and oral hygiene routine.

3Past history, medicines and allergies

  • Medical history, updated at each course of treatment.
  • Current medicines and allergies.

4Social and family history

  • Occupation, smoking, alcohol and anything else relevant to the complaint.
  • Family history where it changes risk or management.

5Examination

  • Extra-oral and intra-oral examination, with charting.
  • Radiographs taken, with the justification and the report.

6Impression

  • Diagnosis for each tooth involved, with the treatment options.

7Plan

  • The treatment plan and its cost, agreed with the patient in writing.

8Safety-netting

  • What should prompt the patient to get back in touch, and how.
  • When the next review is due.

Draft

[Clinician name]

[Role], [registration number]

Signed [date], [time]

How the wai scribe fills it

The same note, written from an invented consultation.

Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.

01Initial consultation note

SignedAI-assisted, edited by the clinician

Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person

Dental initial consultation note

1Presenting complaint

  • Sharp sensitivity to cold, lower left.00:25

2History of the presenting complaint

  • Several weeks. Pain resolves on removal of stimulus. No night pain.01:10

3Past history, medicines and allergies

Completed by the clinician from the record.

4Social and family history

Completed by the clinician from the record.

5Examination

  • Lower left first molar, distal caries visible. Bitewing radiograph taken, caries into dentine.03:30

6Impression

  • Dentine caries LL6, reversible pulpitis.04:40

7Plan

  • Composite restoration LL6. Treatment plan and estimate given in writing.05:20

8Safety-netting

  • Advised to call with night pain or swelling.06:00

Signed and filed

[Clinician name]

[Role], [registration number]

Signed [date], [time]

Questions

What goes in a dental initial consultation note?

Presenting complaint, History of the presenting complaint, Past history, medicines and allergies, Social and family history, Examination, Impression, Plan and Safety-netting. Each section on this page lists what belongs in it, written for dental.

Is the worked example a real patient?

No. The consultation is invented for this page, and no real patient or record is used.

Does the scribe sign the note?

No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.

Can we use our own note structure?

Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.

The initial consultation note in other specialties

All clinical notes
  1. Private GPPrivate GP initial consultation note
  2. DermatologyDermatology initial consultation note
  3. AestheticsAesthetics initial consultation note
  4. FertilityFertility initial consultation note
  5. PhysiotherapyPhysiotherapy initial consultation note
  6. Mental healthMental health initial consultation note
  7. Longevity medicineLongevity medicine initial consultation note

Further reading

  1. ProductThe AI medical scribe for clinics
  2. Read nextWho signs an AI clinical note, and how to review it
  3. Read nextSOAP and specialty note templates for an AI scribe
  4. RegulatorThe CQC compliance hub

Come back to the note, written and ready to sign.

See the wai scribe write a dental initial consultation note on your own structure, in a 15 minute video call.

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